Photo above: Museum of Contemporary Art (MACRO), Rosario, Argentina
Generally, psychoactive medicines are thought to posess the virtue of facilitating, preparing or even opening the field where analytic working-through, (or something like it), might develop.
It is also argued of “mental illness” that it should be considered a solid, objective and objectifiable entity (e.g. through objective measurement techniques such as multicentric questionnaires). Therefore, apart from and beyond objectivated suffering (or of its side of jouissance) the illness is supposed to exist as a foreign body, and the pharmacological object is ready to attack it. Likewise, beyond the signifier (a phobic fantasm, an obessive ritual, the “pain of being”) lie the neurotransmitters, this new metamorphosis of the old hypothesis of an organic disorder.
If the brain must then be considered thought’s material support, it the “verifiable facts” command, must then thought itself admit that the power of the neurotransmitters precedes and makes words possible? Even desire should be reduced to the interplay of opiate autorreceptors?
A psychoanalyst, working as a Liaison-Consultant at a Public Hospital, stands between different worlds; an incessant confrontation between Psychoanalysis and Medicine, between the field where subjectivity may briefly appear as a glimpse, and Science which necessarily excludes the individual. Psychiatry, as a by-product of Medicine that cannot preclude subjectivity otherwise than by trickster tricks (psychoactive medicine as one of the most conspicuous of these), is a controversial affair which shall be questioned here from a psychoanalytic outlook, taking several observations as a starting point.
I. A Liaison-Consultation is demanded in an inpatient department; the patient has a former diagnosis of “bipolar disorder”.
The interview takes place in her room, where she lies in her bed, her sister at her side. Between both stands the small night table; on top of it, a display of the medicines she takes. These are in adequate correspondence with her diagnosis: torrents of lithium, streams of carbamazepine, waves of chlonazepam.
– I have some periods of euphoria followed by periods of depression – she says. The psychiatrist insists that it’s convenient for me to remain always “at the same level”, without those ups and downs – her sister adds.
– How’s that “euphoria” like? – I start to inquire.
– Well, everybody insists that I speak too much, too fast, and I certainly feel happy.
– But – I insist – does that mean any trouble to you?
– No – is her answer- none at all.
– And the “depression”?
– Ah, when it comes, I like to stay in the dark until midday.
– And after midday?
– I go out to do my everyday shopping, as usual.
A few days afterwards, I narrate the case to an expert psychiatrist. He explains that there are two different psychiatric criteria: the “categorial” one, in which signs of a “category” (e.g. “bipolar disorder”) are looked for, and the “dimensional” criterion, in which a “minimum sign bipolarity” is supposed to exist, and this must be attacked with medicines to prevent the development of the full “illness”.
II. Psychiatric texts, lectures, etc.
1. Reading through different volumes of a Journal, General Hospital Psychiatry1 we find, after several pages overcrowded with statistics, the report of a case. (Only one).
Does this contradict and rule out the statement after which psychiatric papers do not consider the subject, the clinic of singularity? 2
Let’s consider the actual text: Patient A., a male aged 25, was admitted for 4 days following an overdose of carbamazepine, paracetamol, and flucloxacillin. He underwent a gastric lavage… He had a positive past psychiatric history that included a previous overdose and psychiatric admissions. A previous diagnosis of borderline personality disorder was made… he was restless and verbally aggressive. He threatened physical aggression. He continued to express suicidal ideation… Due to his physical condition, psychotropic medication could not be used initially and his behaviour was managed by providing one-to-one nursing for the first 2 days on the ward…
The clinical aspects of psychoanalysis are “what is said in a psychoanalytic cure”. And clinical psychiatry is “what is seen in Psychiatry”. Any trace of the patient’s discourse has been erased, substituted by observations on exteriority – in which only two rudimentary paraphrases survive as minimum, inevitable remainders – a surface that acts as a screen to hide the forclosed subjectivity even more.
2. Resuming our reading, we find a remedy to the scandal of jouissance: chemical castration. Does this mean that if symbolic castration is defective, real castration might replace it efficiently?
Men with deviant sexual behavior (paraphilia) are usually treated with psychotherapy, antidepressant drugs… however, these treatments often are ineffective. Selective inhibition of pituitary-gonadal function with a long-acting agonist analogue of gonadotropin-releasing hormone may abolish the deviant sexual fantasies, urges, and behaviors… by reducing testosterone secretion. The authors conducted an uncontrolled (certainly so!) observational study in which 30 men were treated with monthly injections of triptorelin… 3
Hyppocrates made his disciples swear that they wouldn’t ever castrate their patients, not even if they asked them to 4; nevertheless, times seem to have changed since then…
3. News on Diagnosis.
During a class within a Course on Psychopharmacology, a revision assessment is presented. 60% of the diagnosis of schizophrenia are totally wrong. If delusions are considered in addition, the amount soars to 90%. Even Lacan has muddled up the scene with his unjustified emphasis on neologisms and holophrases: delusions and hallucinations are not exclusively pertaining to schizophrenia. In most cases what it really is about is Bipolar Disorder. (Almost) all the so- or now-called “borderline disorders” also are really Bipolars.
Retrospective considerations show the devastating consequences. Years of massive haloperidol administration have reduced thousands of patients to a “vegetable” status. They could have had some kind of “social life”, had they been put on… lithium. We may give credit to the psychiatrists’ mea culpa, yes, but… won’t they lament, some years from now, the devastating effects of lithium (on kidneys, liver, etc), which they are happily and abundantly providing now to their now correctly diagnosed Bipolars?
Before leaving, the Professors comment the investigation they are currently carrying out. Sponsored by a powerful French Laboratory, they pursue the genetic origins of Bipolar Disorders. They ask for help, i.e. volunteers to provide anonymous blood samples (prior signed informed consent) to send to France and analyze their DNA.
They write the address and telephone number on the blackboard.
- Should we create an addictive society?
An “interactive” course. The audience is not allowed to ask questions directly to the lecturer –, as it was usual in pre-technological, vanished times. These outdated habits of the past are replaced by multiple-choice questions that appear ready-made, projected on a screen. Each member of the audience is provided with a gadget to answer with, by dialing the corresponding number. Any dialogue is excluded, technology has eliminated it.
A lecturer is at odds with statistics that indicate that there is still a small part of the inquired individuals who prefer not to have any psychoactive medicines prescribed. A remainder of the dark ages, probably. Fortunately, the rest of the population says yes to medical discourse and even demands the pills. Our new Knock 5 realizes that there is still a lot of work to do to rectify public opinion and attain complete conversion. Extra medicinam nulla salus.
Another lecuture follows, on biologic resources to cope with panic disorder during pregnancy. ECT is highly recommended, as it prevents the risk of post-partum infanticide.
Can we deduct that it was something that the pregnant woman/women said which allows the lecturer to fear those risks? Mortification of the Flesh is the punishment for Bad Desires; nowadays, Science replaces a monk’s cilicium with electric current.
IV. Back to Liaison-consultations.
– I have depression – a patient says – and went to see a neurologist. He diagnosed Major Depressive Disorder.
Naturally, he exhibits several small boxes of an ever-changing series of antidepressants, currently or formerly used. There hasn’t been any change with them; due to his age, he was removed from service and lowered in category. From driving the General Manager’s automobile, he had to sink to steer the vehicle of lower employees. Retirement 6 came soon afterwards, involving a feeling of futility, the frugality of a minimum income. A predicament that fluoxetine, designed perhaps strictly for energetic yuppies, does not reverse.
Another patient says: – I was told that “panic attacks” is the name of what I suffer.
She adds, however, that with the succulent dosis of chlonazepam that she receives she feels dizzy as a zombie. She sees her psychiatrist once a month. Now, her terror is at the possibility of – lacking the pill!
Another one still: – I’m a Bipolar. The psychiatrist urged me to join a self-helping Bipolar Group.
A crucial point during the medical act is the communication of a diagnosis. In the psychiatric field’s swampy territory, torn between the enclosure of Medical Order and the opening elicited by a subject’s demand, does not a nominative sentence involve its risks? For the analyst, a please doctor, what do I have? as an expression of the irreductible aspect of demand, impossible to be questioned any further if it is supressed or muzzled with a hasty, premature answer, sets him before his task: to persevere as an analyst, without any ready-made recipes taken from established (“known”) Knowledge.
Neither abstinence nor neutrality are a concern for the psychiatrist, when he delivers a label to his patient. The fact that neurosis establishes a pseudoidentification with this signifier, and that anxiety (either diminishing or increasing) shall be henceforth associated with it, does not worry him. Neither does the fact that a hysteric might test and question his authority, as way of sustaining the Father. Small talk: words are but superficial phenomena, without any material substance, a mere, superficial by-product of the Ball of the Neurotransmitters; these are regarded as the material and efficient cause.
Experimentation with human beings becomes the quest for the suspect neurotransmitter: first aiming at the production of a specific one (reuptake of serotonin), then interfering with another (noradrenalin), then both (“dual” inhibitors), or even three of them at once, and so on. But what about the “ecologic” disorder created in the meantime? The question seems nearly out of place, considering the expected marvellous results, as well as the emphatic certainty of the Scientific Information provided by the producing laboratories. Paradoxically, this information reaches us again by words… 7
Psychiary knows in advance what is Good or Beneficial to the Organism. The Pharmacon (or electric instruments, or even surgical instruments) is/are the object/s that promises to alleviate or cancel “suffering”. There is no need to ask whether this alleged suffering does or does not fall together with the demand, or even if the latter acts as a screen for desire. (Naturally, the responsibility of the subject is not lesser: seeking a safe hideout may comply with the Master’s commands). Not long ago, a post-freudian medical deviation pretended that “systematic interpretation” was identical to the pharmacon’s action: the larger the dosis, the greater the effects. Returning to Freud is also a risk, if its signifiers are placed in a dominant position. The analyst can only have the place of a “wise ignorance” (ignorantia docta) to produce a questioning subject: Timaios asks Socrates:
I wish you to give us the best, and most perfect pharmacon, that is,
1 20, 73-77, 1998, Elsevier Science, Inc., New York.
2 Neuburger, R., Integration of a Psychoanalytic Liaison-Department at the Public Hospital. Journal of Psychiatry and Clinical Neurosciences, Folia Publishing Society, Tokyo, Vol. 54, No, 4, August 2000, p. 399-406
3 Rösler, A., Witztum, E., Treatment of Men with Paraphilia, N. Engl. J. Med., 338: 416-22, Febrero 12, 1998.
4 Ού τεμέω δέ ουδέ μήν αιτούντας (Ιπποκράτης, Όρκος)
5 In Jules Romains’s comedy (Knock ou le Triomphe de la Médecine, starring Louis Jouvet in the first performance), Knock – a fake doctor – takes over a medical consultation room in a small country village, submitting every one of its inhabitants to the Medical Order. His motto is: Every healthy patient is an ignored sick individual.
6 In Argentina, retirement usually means inactivity plus the lowest possible income, i.e. nothing whatsoever to rejoice with, despite the Spanish term (jubilación).
7 Needless to say, this paper describes a specific (ab)use of psychoactive drugs, and some of its Imaginary aspects. Other , more propitaitory possibilities are not considered here (e.g. see D. Paola, The use of a psychopharmakon in transference introduces a metaphor in the Real, Psicoanálisis y el Hosopital, No.9, 1996, p. 71 – in Spanish)
8 Plato, Κριτίας, 106b