- case history;
- general hospital;
A general overview of liaison-psychoanalysis in a general hospital is presented. The team’s trajectory is revisited, as generating a presence in the inpatient units: a demand which changes from a purely psychiatric, scarcely operative level to an acknowledgment of subjectivity. Generally, this appears disruptively in medical proceedings. Two case histories are presented: (i) ‘the tenant’ and (ii) ‘the nail-polishing file’. With regard to the first case history, the transference in its double aspect, with the patient as well as with the unit’s staff, is examined. The analyst’s intervention seeks to untangle the impasse, which prevents the physicians from helping the patient. With regard to the second case history, in which the de-mystification aspects of liaison work are shown, the horror that the so-called ‘mental illness’ can produce in the medical institution is explored. The aim of narrating this experience is to preserve a psy-space in the hospital where the overwhelming technological developments menace with its disappearance.
The psychoanalytic-liaison team, which usually is part of a psychopathological department in a general hospital, is the articulation point between both the department and the hospital itself. Several documents of this experience attest to this. In each of them the characteristic features of the particular context in which the experience took place may be considered.
In March 1994 in the general hospital, ‘Dr I Pirovano’, an attempt was made to establish a full-time liaison team. Formerly, this task had been carried out by psychiatrists with other responsibilities: psychiatric emergencies, psychopharmacological support of psychotherapies or analyses etc. However, the significant difference with the former undertaking was not only the exclusive dedication to liaison-work. Indeed, the former physicians’ practise was devoid of any psychoanalytic reference. It had been, therefore, impossible to consider liaison-consultation as a psychoanalytic act and effect of discourse. †
Reading through the papers on the subject, a simi-lar state of affairs may be found whenever liaison-work is considered from a purely psychiatric perspective. ‘Facts’ are presented in a statistical exhibition, to us by no means demonstrative in itself (e.g. Which inpatient departments demand liaison-consultation and how often? Which type of ‘pathology’ is seen most frequently? Which are the psychotropic drugs most frequently prescribed? etc.). 5–8 There is no place whatsoever for any single (i.e. singular) case history: formally, this omits subjectivity altogether, as well as the conditions of its production. ‡
The establishment Psychopathological Departments within general hospitals generated the procedure of liaison-consultation, which soon became known through appropriate publications. In Argentina, after the creation of the corresponding department at the Policlínico de Lanús by Mauricio Goldenberg in the early 1950s, the first reports on liaison-work by Valentín Barenblit and Juan J. Criscaut became known. 9–12 Likewise, papers by Ferrari and Luchina reflect the nearly simultaneous experience at the Hospital Ferroviario. 13,14 That is to say, the clinical horizon of liaison-practise was interpreted from the beginning by means of the psychoanalytic method, and the experience transmitted according to the post-Freudian development of the moment. 15,16 In a subsequent paper by Chevnik, an attempt is made to describe the activity by means of Winnicott’s concept, the ‘transitional space’. 17
After the introduction of Lacan’s thought and teaching in Argentina, an endeavor carried out by Oscar Masotta and documented or followed by an ever-increasing number of publications, the book by Jean Clavreul, ‘The Medical Order’ appeared in 1978 (French edition; the Spanish translation was issued in 1983). 4 One of the first papers (by Silvia Chiarvetti and Eduardo Gandolfo) to work through its concepts portrays the difficulty of establishing a ‘psy’ space within the medical institution. 18 Evidence is presented of the missed encounter between medical order, which is a derivative of the discourse of the master, and analytic discourse. The former, in its dependence on science (as we pointed out earlier) forecloses the subject, the aim of the latter being precisely its production. Lacan puts forward ‘algebraic formulae’ in which the different discourses are defined by the different position of the same four elements. §
It may be remembered, however, that this is a description of a structure, not to be mistaken for the individuals who represent it. Physicians may, whether on purpose or not, shift from one position to another. For instance, they may listen to their patients without immediately considering what the patient says as a sign, only meaningful as such within their task as physicians. In a certain moment, however, practicalities will force them to do so; that is to say, to return to the medical order.
And yet this order, which aims at an illusory totality, may suffer a cleft due to the vicinity of the ‘real’, as signaled by anxiety.d This is the releasing moment of a demand for a liaison-consultation. JJ Criscaut describes it as the beginning of a ‘consultation sequence’. 12
Transference, according to Lacan, is ‘a useful imposture, since it fills the void of a deadpoint’. 22 In the same sense, even though the demand may be to eliminate the gap in medical order, the psychoanalytic liaison-consultant’s purpose by no means is to fulfil such a seam or suture. This may be, however, the goal of psychology – more so the more scientific it pretends to be, aiming itself at an encyclopedic wholeness. The same may be said of any multi or interdisciplinary program. Psychoanalysis, on its side, always unveils, or stumbles with, an unavoidable fault, an irreductible incompleteness. ‖
In addition, different transferences interweave, setting up the problem of their direction. The analyst must listen to the physician, to the patient referred to him/her by the latter – this means that the patient has not him/herself asked for the analyst’s intervention – and, furthermore, acknowledge the full weight of the ‘institutional transference’ (i.e. the particular signifiers driving the patient to seek that particular physician’s – or hospital’s – help. 24–26
As we may see, this is not a ‘harmonic’ situation, not even a lost harmony that has to be re-established. What’s more, some papers 27 describe it as a ‘nonrapport’, a basic or original missed encounter. ††
The analyst may, as a consequence, shed light upon the institutional breaches. The possibility of an effect in the real is not excluded, resetting in motion a medical act, which had remained temporarily suspended or stuck. ‡‡
The two different discourses are matched with two different concepts of the body: to science, the body is objectively measurable. To psychoanalysis, the body is but an array of signifiers. This is the point where ‘psychosomatics’ may either progress or shipwreck. §§
Another discursive cross-road is Balint’s effort. On the tracks of Ferenczi, his predecessor, Balint attempted one of psychoanalysis’ first incursions into medical territory, through his discussion groups of physicians. 28–30 The effects of the signifier, the irruption of the subjective rift within medical order, are brought to light and investigated, starting from the signifiers produced by the doctors themselves. ¶¶
The current exercise of the team was organized according to different axes:
Overcoming some of the resistances within the Department; going beyond the psychiatric feud and through the difficulties of a ‘psy’ to enter an unfamiliar (unheimlich) domain, that of physical suffering, of a body wounded or dismembered, the real vicinity of death.
The beginning of our experience, answering the written demands for a liaison-consultation.
Bibliographic study and research by all members of the team; obtaining new testimonies by per-sonal communication with former or current experienced liaison consultants working at other hospitals.
A weekly supervision whose aim did not limit itself to case histories but attempted to go beyond these and investigate the field of liaison-psychoanalysis together with its definition.
A monthly discussion group with an institutional group analyst. Sooner or later, any group produces the imaginary phenomena described by Freud in ‘Group Psychology and Ego-Analysis’, which disturb or hinder the group’s tasks. This monthly reunion tried to prevent or limit their appearance.
The team took part in rounds and reviews together with the inpatient division staff: physicians, nurses, kinesiologists etc.
These ceremonies are carried out as follows. During the review, which took place in the physicians’ office, a resident physician reads new case histories aloud (or stated new facts concerning previously committed inpatients). The round is a procession of the whole staff along the inpatient division, stopping beside each bed to discuss a particular topic.As a result of our constant presence, further demands were made spontaneously and personally during the aforementioned procedures, not only by means of a written form. Indeed, this form, handed over by administrative personnel, frequently reached us too late (i.e. when the possibilities of a successful intervention had already become scanty).The demand increased steadily; its contents likewise changed from apparently pure psychiatric cases, where only a pseudoscientific sanctification of an already prescribed tranquilizer was asked for, to patients whose subjectivity was first acknowledged and who were then referred to us.Meeting colleagues, members of similar teams working at other public hospitals, allowed us to observe similar historic developments. Finally, our presence in rounds and reviews ceased to be necessary as the team’s members became well known within the Division. Medical proceedings include a wealth of medical information, which, if not unnecessary, is frequently irrelevant to our practice. By then we had been identified by the medical staff as ‘others’, to whom a certain knowledge was attributed.
The team also took part in the weekly meetings of the Adults Division of the Psychopathology Department in order to complement liaison-consultations with referral of discharged in-patients to psychotherapists or analysts when necessary. The Department’s seminars were likewise attended.
Let us turn now to some examples of our clinical experience. ‖‖
During one of the rounds, a staff doctor asked us to solve a pathetic case, which he called ‘hospitalism’.
A diabetic woman whose leg had been amputated had remained since then in her bed, refusing to be discharged for over 1 year; an unheard-of predicament considering the Hospital commits acute diseases only. A member of the team faced the enigma. The patient rejected her: never before had she accepted a psychologist, and did not even think of doing so in the future, whether near or remote.
The ward’s staff, be it silently or by means of medical jargon, surrounded the woman’s refusal with a stiff, icy atmosphere.
The analyst insisted, nevertheless, displaying all of the artifices that her clinical intuition was able to supply to face the annoyed Medusa. And, believe it or not, she succeeded, changing her into . . . a proselyte. The same woman who had furiously rejected her then longed for her presence, complaining when the analyst was late or unable to attend the hospital.
This brought the long hoped-for acknowledgment of the staff, still mingled with a certain amount of disguised skepticism.
However, new difficulties arose. The patient’s family refused to attend an interview. Again the analyst insisted and succeeded. The relatives finally appeared; they ended up unwillingly describing their scanty dwellings, which even lacked a floor. The reason for the patient’s desire to remain in the hospital seemed evident enough.
The analyst discovered yet another fact. The patient did not observe her prescribed diet, placing herself at risk with transgressions. Apparently, the staff just ignored this. The analyst quickly identified the key to this indifference: psychologization. The staff attributed to her the intention of self-aggression whenever anyone told her that she was to be discharged. The patient was supposed to be able to change her metabolic patterns by a mere psychological action which would prevent her discharge, allowing her to remain there as a tenant for ever, or at least as long as she wished to.
The analyst carried out her first intervention, the goal of which was to produce a dialectic inversion of the extrapolation of knowledge that she had been able to find out. She explained and demonstrated to the staff that the possibilities of motivation were strictly limited.
Meanwhile, she continued to meet the patient, trying to demystify the role she has chosen (that of a tenant). This position was by no means a privilege, as her Imaginary would wish to believe or beautify, but that of a waste object. Indeed, the price of her fantasy was the loss of her other foot.
The second intervention, again with the staff, had a deferred action upon the first one. The analyst aimed to restore the woman’s category as a patient, the medical act having been practically suspended during her stay. During the round, for instance, her evolution was scarcely, if ever, mentioned: physicians just used to pass by and say that the room merely harbored a tenant.
THE NAIL-POLISHING FILE
Mental sickness! A despairing cry, coming out of the terrified throats of the surgeons in another Department, even though their Herculean arms certainly would never retreat in front of any other menace, runs through the Hospital’s corridors. The Institution’s walls shake and seem to crumble with the prospects of such a scandal, obscure, undecipherable, opaque . . .
Often a significant aspect of working through the transference (the patient’s as well as the physician’s) consists in demystifying imaginary dangers. Indeed, the myths, which grow within a Department, seem at times to grow huge yet last for as little time as a snowball.
For instance, a previous, and successful, suicide attempt, which took place within the Inpatient Department, heavily cast its ‘mythopoetic’,k shadows ever after. Subsequent events, without any actual relationship with the former suicide, inadvertently clad themselves in a tight bulk of imaginary garments.
A liaison-consultation was ordered for a young woman. Little was known about her; she came from an asylum, having thrown herself over the walls – an attempt to escape from confinement, or from life altogether?
She lay motionless, her limbs tightly cast in plaster and orthopedic devices. These were not her main shelters, however, her major parapet being an inaccesible mutism, interrupted only by scarce monosyllabic utterances.
Another fragment of the legend that was attributed to her was that she attacked a fellow inpatient, a shoe in her hand as a weapon. She had become pregnant, and then transferred from the asylum to a maternity hospital to deliver. Did the child’s birth make her already failing mental health even worse, driving her to attack the woman in front of her? She was immediately carried back to the asylum. The child was put under custody – nobody knew the judge’s name or the child’s whereabouts. The young mother came from a distant province and owned no lodgings other than the open air.
The liaison analyst had thus to unravel a mysterious and obscure secret. She had to endure long, painstaking sessions where the patient remained absolutely silent. At a certain point, however, the patient became able to speak. What the analyst had to listen to was by no means propitiatory. Indeed, the patient’s life had been a true labyrinth of horrors: a family dwelling in an unattainable jungle, reached neither by letters nor telegrams, in permanent, extreme violence. Her father was the character she most feared. She dared not return, lest endangering her own life; home-less, she earned her bare living as a street prostitute and was committed to the asylum by policemen, as ordered by the Courts’ bureaucratic coldness. Physical pain resulting from her leap over the walls was but little compared with the suffering elicited by the lack of answers from the social and professional milieu.
The analyst decided to become a patchwork, temporarily creating a bridge over the institutional shortcomings and gaps. She tried to interview witnesses of the young woman’s stay at the asylum, or the judges who sentenced her to seclusion; she attempted to reach the distant family (to no avail) and endeavored side-by-side with the Hospital’s social workers to find out the child’s whereabouts.
All this activity, far from producing the analyst’s ‘burn out’, brought forth subjectivity instead. The patient became able to express her wish of having her child back again.
At one moment the analyst was urgently summoned to rush to the Department. Someone (perhaps a nurse?) had seen the patient with a knife in her hand. The worst consequences were imagined. The whole hospital might have had to mourn, stained with heavy responsibility charges.
The analyst arrived. The patient calmly explained to her that she merely attempted to cut the elastic band that fastened her leg’s traction: she just couldn’t bear the pain anymore. The physician in charge hadn’t acknowledged this. The analyst asked another traumatologist to examine the device; this traumatologist realized, indeed, that the device should have been put away and discarded long ago. Perhaps it was just left there to keep the patient securely fixed to her bed . . .
From an apparently closed starting point and after a strenuous working through, the analyst witnessed the appearance of one of the formations of the unconscious: the joke. She has brought the patient, at the latter’s demand, a nail polishing file. The woman is now able to move her feet, and complains that a ‘bad little finger’ (she points to it, personifying it, playfully reprehending it) has torn her stocking.
The patient becomes able to walk. Seeing her go through the hospital’s corridors the analyst suspects the unavoidable outcome. The patient leaves the hospital without waiting for her official discharge, going back to the streets. The menace of being committed again by the police is no drawback to her desire.
Which are the tasks waiting for our liaison team, and what may be the aim of narrating its experience? In her article, ‘Liaison-psychoanalysis: a practice of discontents’, 32 Silvina Gamsie analyzes with devastating minuteness the impasses met by analysts at hospitals. Needless to say, it may have become quite clear that our paper also reflects this predicament. However, are these obstacles not reasons to persevere, to try to sustain psychoanalysis’ ethics, as opposed to official science which seems to forget ethics altogether in its blind quest, allowing technology to become increasingly overwhelming?
A former version of this paper was written in collaboration with Cristina Beiga, Diego Dileo, Juan J Criscaut, Mariela Skef, María Vicente and María Claudia Walsh.
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A SHORT GLOSSARY OF LACANIAN TERMS
(Terms in italics generally refer to other entries in this Glossary) †††
Act: ‘Behavior’ is pertaining to all animals; ‘acts’ are only symbolic, performed by responsible subjects, even if unintentional (parapraxes).
Demand: see Need, Demand, Desire
Desire: see Need, Demand, Desire
Discourse: a social link based upon language. There are four types (structures) of discourse (the Master’s, the universitarian’s, the hysteric’s, and the analyst’s).
Words always involve an Other: the Unconscious, according to Lacan, is ‘the discourse of the Other’.
Fault: In Plato’s Symposium, Socrates presents the wish as originated in a lack (one wishes only what he doesn’t have). The central concept in psychoanalysis being the wish (Freud’s Wunsch) or desire, the ubiquity of the concept of fault in Lacan’s writings may be easily understood.
Foreclosure (or Preclusion): Lacan’s original translation of Freud’s term Verwerfung (rejection), a mechanism inherent to psychosis (while repression is intrinsic to neurosis). It is a complete absence of symbolic inscription of a signifier (repression prevents the consciousness of a signifier, while keeping its unconscious inscription), a failure in the Symbolic order which leaves a permanently dangerous hole. ‘What is forclosed from the Symbolic returns in the Real’.
Imaginary: see Real, Symbolic, Imaginary.
Missed encounter: Lacan raises the problem reinterpreting Aristotle’s terms tyche and automaton (usually translated as ‘chance’ and ‘necessity’). The first term depicts the Real, impossible to be covered by and never fitting in the chain of signifiers (which stand for the second term). The attempt to account for negativity in psychoanalytic experience is the origin of several Lacanian negative statements (impossibility, impotence etc.). See also: Fault.
Need, Demand, Desire: The first term is close to animal instinct. In human beings, however, language permeates and deeply modifies everything, thus being more exact to use drive (Freud’s ‘Trieb’) rather than ‘instinct’ (unfortunately, the difference was blurred by Strachey in his translation). There is no exact meeting, no ‘harmonic encounter’ between the drive and its object, as there is between the instinct, the need and that which satisfies them. Furthermore, the entire organism as a whole participates in an instinctual behavior, while the drive is always a partial one. There is no ‘natural’ object of the drive, only substitutes. Likewise, the infant has to pass his/her so-called needs through the expression of a demand (the infant’s cries have to be interpreted, signified, by the mother). A certain distance, a difference between demand and need always remains unstilled, unquenched: this is called desire. Freud presented the question as early as in his unpublished draft Project of a Scientific Psychology.
It should be remarked that the term ‘demand’ is used in this paper both in its unspecific, loose meaning as ‘demand for a Liaison-consultation’ and its analytical meaning.
Psy: an abbreviation that stands here indistinctly for ‘psychoanalytical’ and ‘psychological’. These are– admittedly–very different concepts; however, in Argentina most psychology graduates follow a psychoanalytical orientation.
Real, Symbolic, Imaginary: the basic triad in Lacan’s teaching (‘orientation compass’). The Real is one of the most difficult, paradoxical concepts, being entirely different from ‘reality’ (which is a product of discourse, with imaginary overtones). Resulting from the insufficiency of the Symbolic to articulate everything in words, only negative definitions are possible (e.g. what is left beyond the Symbolic borders: the Body as an organism, the void and silence of the death drive). The Imaginary order deals with images, as active during the mirror-phase (human beings from 6 to 18 months), illusions, sexual behavior or parade as described by ethologists, decoy phenomena and aggressivity. The symbolic order deals with articulate, discreet elements such as present in language (‘the unconscious is structurated like a language’).
Sign: Lacan uses this term in its usual sense in linguistics (Pierce), to oppose it to the signifier. The former, being ‘what signifies something for someone’, has a relatively fixed relationship to its meaning (e.g. the sign in medicine), while the signifier’s relationship to the signified is highly unstable.
Signifier: a term borrowed from the structural linguist Saussure (who distinguished two aspects of a sign: the signifier and the signified) and very much changed, the signifier in Lacan’s theory having primacy and relative independence over the signified. Signifiers are the articulated elements of the Symbolic order, while signification is always imaginary. The subject takes the signifiers he identifies with (identification process) from the Other (‘man’s desire is the desire of the Other’). The analytic experience has signifiers as its material, never an ‘objective reality’. Signifiers being never isolated, it is necessary to represent the signifying chain with at least two of them: S1, the chain’s origin, i.e. the Master signifier (Freud’s einziger Zug, ‘unique trace’), and S2, an abbreviation, which stands for the group of unconscious representations.
Subject, Subjectivity: a concept based upon, but dif-ferent from the philosophical term (gr. ypokeimenon). Distinct from the concept of ‘ego’ which is an imaginary agency, the Subject (of the Unconscious) is a product of discourse (talking-being, fr. parlêtre). To avoid any possible objectivation, Lacan only produces negative definitions of the subject (e.g. the subject is what is represented by a signifier to another signifier).
Symbolic: see Real, Symbolic, Imaginary.