The validation of psychoanalysis. From Cure to Care

Nicolás Caparrós M.D.

Can we speak of a standard cure or may be of several cures? A crowd of theories, models and even conjectures plays different roles in order to solve this question: those about mental health, illness and also ideology…, any way, old and new problems.
The development of science process is not the only one that identifies concrete troubles and places Them in the continuum of material reality. The ideology plays the same role related with its own aim about what is the genuine scientific object. For instead, the hegemonic ideology upholds the thesis that identifies Science with Scientific-Positive method. That is to say, both concepts looks as synonymous. Eysenk, Popper, Lakatos, etc, are outstanding examples of this position. Their consideration about science status is worth of attention; but nevertheless it can´t be equated with a more wide epistemological point of view.
What about psychoanalysis? Is it a science; a natural science? Maybe a motivation science, a semiology of behaviour? Or can we deal with psychoanalysis as a sort of hermeneutic or even with a technology?
For our present purpose, the central point is that the concept of cure was related even in psychoanalysis with the idea of illness. Cure and illness belong to the realm of biology. But when psychoanalysis was growth, cure is no more a mechanistic metaphor taken from biology; on the contrary, talking cure attains its own specific laws. Meanwhile, we must point out the complex problem of the so called psychic causality, as A. Green uses to say. In this frame the utmost background of cure has a new sense. It is no longer neither a biological enterprise nor a psychological one; background of cure is the unconscious that is to say: a psychoanalytic affair.
Last but don´t least, let us pay attention to the spread idea of change. Can we identify cure with change? Not at all. This confusion encloses a displacement of the epistemological perspective. As we said before, cure is a natural scientific concept that acquires in psychoanalysis a new sense by means of a tentative metaphor. Change is far away of health-illness dialectic and also exceeds psychopathology field.
Change tries to be objective, the sacred aim of positive science with the consequent contempt or ignorance of subjectivity. The search of objectivity is the banner of positivism as defender of Science (Varela 1988). The notion of change without contingent and concrete values is a nonsense in the integration level of psychic. In this level we deal with intentions, sense and affects linked with thought, free affects, representation, unconscious and emotional developement.


Values are in the foundation of categories as Edelman says in his model of neural Darwinism.


SOME FREUDIAN REFLECTIONS ABOUT CURE
Psychoanalysis is born as a clinical method. In the beginning we are in the hysteria´s kingdom. Cure in those days is very near of biology.
The cure concept is present from the origins:
I have from nine to eleven hours of hard work, from 6 to 8 cures daily.
Freud-Fliess 11-29-1895.
Hysteria is no longer an interesting matter for psychiatry; neurology guides its attention to other fields. Babinski announce the bankruptcy of hysteria. The banner of hysteria is now with Psychoanalysis. The investigation of this neurosis opens the discovery of repression and the fact that the repressed is in the unconscious. The key point is that defence from sexual drives represent the beginning of real psychoanalysis.
Clinic and Metapsychology ride together.
But unconscious seem to banish in front of resistances and the primitive talking cure is unable to overcome this circumstance. The aim of cure must now cut away its initial ambition. In the Trauma´s Theory, the first frame of psychoanalysis, cure is something like «to get conscious the unconscious». Too mechanical, too simplistic to be consistent. When the Phantasy Theory, that leads to the childish sexuality takes place, facts are far more complex.

So far as 1897 Freud told to Fliess:
If one thus sees that the unconscious never overcomes the resistance of the conscious, the expectation that in treatment the opposite is bound to happen, to the point where the unconscious is completely tamed by the conscious, also diminishes.

In the same letter we see the first signs of Phantasy theory.

Then, third, the certain insight that there are no indications of reality in the unconscious, so that one cannot distinguish between truth and fiction that has been cathected with affect. (Accordingly, there would remain the solution that the sexual fantasy invariably seizes upon the theme of the parents.)

There is a cualitative difference between conscious and unconscious systems. Instead of fiction loaded with affects it should be better to say thing representations cathected with affects. The time flows and from dynamic, economic and topic perspectives emerge different combinations: bound energy, displaced energy that cathects different representations; at last affects are movable entities. Cure becomes a complex, dubitious an instable process.

The unconscious representation that is the object equivalent of internal object, build slowly the nodal point of theory and the discovery of its truly and intimate nature establish the treatment aim.

New remarks about cure in 1904 (On Psychotherapy):
This therapy, then is based on the recognition than unconscious ideas –or better the unconsciousness of certain mental processes- are the direct cause of the morbid symptoms P. 266 […] Psycho-analytic treatment may in general be conceived of as such a re-education in overcoming internal resistances. P. 267.

We register an insistence in the ancient notion: making conscious the unconscious.

There is something new in the letter to Jung of (6-12-1906) just in the prelude of their relation:
I can subscribe without reservation to your remarks on therapy.3 I have had the same experience and have been reluctant for the same reasons to say any more in public than that "this method is more fruitful than any other." I should not even claim that every case of hysteria can be cured by it, let alone all the states that go by that name. Attaching no importance to frequency of cure, I have often treated cases verging on the psychotic or delusional (delusions of reference, fear of blushing, etc.), and in so doing learned at least that the same mechanisms go far beyond the limits of hysteria and obsessional neurosis. It is not possible to explain anything to a hostile public; accordingly I have kept certain things that might be said concerning the limits of the therapy and its mechanism to myself, or spoken of them in a way that is intelligible only to the initiate. You are probably aware that our cures are brought about through the fixation of the libido prevailing in the unconscious (transference), and that this transference is most readily obtained in hysteria. Transference provides the impulse necessary for understanding and translating the language of the ucs.; where it is lacking, the patient does not make the effort or does not listen when we submit our translation to him. Essentially, one might say, the cure is effected by love.

Transference converts past in present and links in a provisional way through the cure ancient feelings with past representation. Transference is a sort of transitional space in which transference neuroses acts as a bridge between psychoneuroses and cure.

I use to say that transference is in some way like an attractor of unconscious representations.
In the transference, emotions play an outstanding role in the path that leads to cure.



The movement of cathexis declines with the year, as Freud says in 1914. A remark about limits in psychoanalytic cure.



There is a turning point in freudian ideas about cure when he realizes that affects are in the background of this process.

Affects functions are seen in three ways: as a discharge, as a matter of tension and as a signal. This reflection opens the way to deal with other problems different to traditional neuroses. But this process will not be ready until the second topic takes place.

The destiny of affect is different to that one of representation. The former is transformed in the contrary, inhibited or suppressed. Meanwhile let us remember that unconscious affect hasn´t nothing but quantity.

Under medical supervision patient must go from pleasure principle to reality principle. Some character-types met with in psychoanalytic work (1916).

This is of course in the limit of idealisation.

THE CURE IN THE SECOND TOPIC
As we said before, second topic gives cure a new frame and another well known idea:
Psychoanalysis makes possible for Ego the Id conquest.
Wo Es war soll Ich werden. Where Id was Ego comes. (The Ego and the Id, 1923).

The Ego, the Super-Ego and the Id are the founders of the new topic and with them come out a crowd of concepts. These are, for our present purpose, the most outstanding:

1.- The Id, a drive container, is an ensemble of throbbing motions in perpetual conflict with manifold manifestations of the antagonist confrontation between Eros and Thanatos.
2.- The Id don´t leave any place for representations, it is made up of cathexis than are looking for discharge.
The consequences of the relinquishment of representation are outstanding. Action is now its substitute.
At the beginning was the action, representation, as a psychic space, will come later.
3.- Eros, like Thanatos, has the aim of discharge. But Eros search the bind (intrasistem, intrapsychic and intersubjetive) Thanatos look for the opposite. This is the most important confrontation.
The bind is from now on a key notion. Bind is a compositum of the drive that looks for discharge in an object, or even creates the object in this very act of cathexis that is Eros. As Green (1984) says Cathexis is not only an economic concept it is also a topographic one. Cathexis (Besetzung) means occupation of a territory. The act of cathexis occupies, decathexis is emptiness. Creation and subsequent destruction in perpetuum mobile.
4.- Let us make now a new inquiry about Drive, a concept on the frontier between mental and somatic. Some psychoanalysts try to ignore this notion in order to keep themselves in an ideal psychic space; other introduced psychobiological concepts to substitute drive, extracted from neurosciences sciences.
Freud named as soma the body representations in state of neediness. So the drive´s source is inscribed as representation (Vorstellung) in brain structures whose organization only involves the pressure (Drang).
Drive means primacy of affects.
5.- The duality Eros/Thanatos provoke that the full human sexuality is displaced by the mechanical sexual function.
Mistery is the kingdom of both life and destructive drives in so far as their origin and present being. The life drives, may be extracts their core from the first organized movements of the matter; the destructive drives from the original desorganization. (P. Marty 1976, p. 13)
6.- Unconscious is from now on a quality and not an agency as in the first topography. The free space left by the ancient agency in the psychic apparatus is occupied by the Id.
7.- The role of aggression find a comfortable place in the second topography. In my opinion aggression – as an affect whose aim is an object opposite to the discharge of life drives, belong to the Eros space. It is a life drive symptom. Aggression, even the so called autoaggression, is always a heteroaggression.
8.- We agree with A. Green (1986) saying that death drives are the same thing than destruction drives. Destruction is the genuine expression of death drives.
Heterodestruction is an attempt to descend inner tension, is a deflection of death drives.
Aggression and destruction are not the same thing.
The function of decathexis, of anti-bind, is to leave the object free, without vitality: object
no-thing (Bion), empty object.
9.- Object reveals drives. We dare to say than is created by them. Object cathexis is a condition for object existence. It was there before, but was, as the philosopher say an
object in it self. The drive act changes it in object for it self.
Winnicott used to say  to create as long as we find. To cathectize means to create, cathexis is possible with the mother´s reverie, as Bion would say or with holding described by Winnicott.
10.- A Green support that the main task of life drives is the function of create an object, (fonction objetalisante) that isn´t limited to the creation of the relation with the internal and external object, moreover is worth to transform an structure in object by means of cathexis.
Discharging finds and create the object and meantime cathectize it.
11.- The function of destroying the object (Fonction désobjetalisante) belong to death drives and is related with the binds breaking-off and with destruction of the cathexis process. Decathexis is the main manifestation of death drive.
The schizo-paranoid position includes the dialectic between death and life drives. Paranoid cathectize the previous projection, schizoid decathectize.
From birth both drives are in perpetual challenge.
12.- Second topography shows with utmost clearness the unyielding aspects of psychoanalysis, those who challenge with the soft adaptative version of Ego Psychology. The eternal presence of drives and specially the antagonistic Eros/Thanatos forbid the final balance with a farewell to the impossible stillness of psychic life.
13.- The environment also takes its place in the psychic life: in this way in the second topography there are a intra-psychic dimension joined to an intersubjetive one.
The drives avoid the easy environmental solution, meanwhile the role of the environment interdicts the biologic determinism.
From now on cure ambitions are more moderate. Cure is defined as the
cathexis redistribution. I think that this is the most accurate concept of cure in Freud´s writings.

In New Introductory Lectures on Psychoanalysis (1933) we read this meditation about cure:
The intention of psycho-analysis is ‘to strengthen the ego, to make it more independent of the super-ego, to widen its field of perception and enlarge its organization, so that it can appropriate fresh portions of the id.
He concludes with his well known statement Where Id was shall Ego be. (Wo Es war soll Ich warden).

Ego increases the importance of its role. Nevertheless we must do the same remarks we did with the sentence: to turn conscious the unconscious: Ego never will gain for it self the uncertain and primal territory of the Id.

Analysis terminable and interminable (1937) is the most pessimistic paper about the therapeutic power of psychoanalysis. Death drives and resistances are the last reasons for this attitude.

A successful analysis doesn´t prevent from neurosis recurrence:
We must guard against a misconception. I am not intending to assert that analysis is altogether an endless business. Whatever one's theoretical attitude to the question may be, the termination of an analysis is, I think a practical matter. Every experienced analyst will be able to recall a number of cases in which he has bidden his patient a permanent farewell rebus bene gestis.1 In cases of what is known as character-analysis there is a far smaller discrepancy between theory and practice. Here it is not easy to foresee a natural end, even if one avoids any exaggerated expectations and sets the analysis no excessive tasks. Our aim will not be to rub off every peculiarity of human character for the sake of a schematic ‘normality’, nor yet to demand that the person who has been ‘thoroughly analysed’ shall feel no passions and develop no internal conflicts. The business of the analysis is to secure the best possible psychological conditions for the functions of the ego; with that it has discharged its task.

From this short outline about cure in Freud´s works we extract two outstanding considerations:

a).- The cure is more and more far of the medical model. Redistribution of cathexis is far away from the medical point of view.
b).- When metapsychology becomes deeper, the linear and mechanical perspective of the former years is overcome by new ones, more structural and complex. The linear is over.

The postfreudian investigations state that cure can´t be evaluated by means of the standards of positivism, nevertheless the frame of science is wider than the positivism field.

Psychoanalysis with its manifold branches is not a psychotherapy. The psychoanalyst aim in the cure process shows than there is between analyst and patient a gap born from the eternal instability among intrapsychic, intersubjetive and the so called objectivity. The more the cure process goes on, the more we realize its anthropologic qualities.

Mashud Khan, under Winnicott´s inspiration, said  that Winnicott felt free to present the paradox that was him to persons than were interested in care, rather than in cure of psychiatrically ill persons. (M. Khan 1975).

Winnicott continues the path traced by Freud. So care appears joined to cure. Care is beyond medical model, care is cure and something more, and something less.

A clinical vignette show all these considerations.

IGNACIO.
I remember very well Ignacio many years after the treatment. He was 35 years old, was married two years ago. He had a little daughter.
Till some months before he was an uncomplicated man in his profession of photographer. He was then diagnosed of multiple sclerosis. The main point in this illness is that the axon is deprived of myelin with serious impairments of nervous conduction.
With great quietness he told me his wish of preserving as long as possible a good quality in his life before the end of his existence. There was some unreal while listening those confidences said by a young man in an undaunted way.
I never before was in such a situation. I am a physician and in front of an incurable sickness there is a normal feeling of impotence, death comes with nothing we can do. But in than chance I was not required to challenge illness. It was not the sick man who came, but the human being, and he was asking for another different thing than to recover health. He didn´t intend to run away from death neither to live a bit more. His wish was to live that short resting period of life as well as possible.
That was the best sample of life drive, the most accurate expression of Eros. Where was then health search? Ignacio met the last deadline of his existence.
At first I felt overwhelmed by these odd circumstances. I suppose that I accepted the treatment because I dare not to reject him. He was respectful and something into me said that was not my right to avoid the situation.
The so called psychoanalytic intervention has for aim the psychic realm, a sort of little island surrounded of a declining biology.
Few sessions after the obvious origin of my embarrassment became clear. It is a non sense to beseech death, we both knew that death was an inexorable happening, but at mean time, announced death is unusual. The task was to accept it, to integrate the rejected in everyday life. To get anxiety vanished, or at least to learn how to deal with it, was our real aim.

Biological death versus psychic life.
The paradox was that the love for life was a pressure for asking for a treatment in order to avoid that his organic impairment erased his own subjectivity, his human being condition.
The cure –I want to call that intervention cure- lasted for two years. We dealt with omnipresent anxiety, with the unbalanced equilibrium between his narcissism and his internal objects, between his affects and his unconscious representations. Life longing and death evidence.
Then end come. I felt that my part of physician failed but the analyst succeeded.
This was of course for me a real cure.

Eros/Thanatos challenge finished with the victory of the former. Meanwhile, death defeated life, a tragic and strange paradox.
Care and cure went together far from the customary path of the medical model.

CONCLUSION
The former case is a good example in order to show that cure in psychoanalysis is far away of the parameters that define the medical model. In medicine cure means to recover health. And health is a biologic concept. We realize that the so called good medicine goes beyond biology and its aim is whole human being. But at last pure medicine belongs to biologic realm.
As Winnicott used to say:
The child´s body belongs to the paediatrician, his psyche to the psychoanalyst and his intellect to the psychologist. The mind is for the philosopher. A very complex problem.

Psychoanalysis is a theory made up of biology, psychology and sociology, different spaces, with different parameters and different properties.
Medical cure differs of psychoanalytic cure. Redistribution of cathexis is far beyond the well known concept of health.

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