It was my first year in a Masters of Clinical Psychology, and this was my first patient at the university clinic. A young woman had been referred for counselling by a GP, notionally for ‘depression’. The initial interview revealed that, for her, she was troubled less by melancholic sentiment, and more by persistent feelings of guilt in connection with her sexual behaviour. She had a ‘slut complex’, as she put it.
After each session it was mandatory for student clinicians to meet with a supervisor, drawn from the academic staff. When discussing possible treatment options, my supervisor asked me which option had empirical support. I answered that the common factors approach had vindicated most approaches. This answer was dismissed, and I asked to implement CBT from a standardised manual.
So, my patient returned, and I attempted to persuade her that her feelings of guilt were distorted cognitions, and that she should record her guilty thoughts on pro forma ‘homework’ sheets, in order that these pathogenic ideas be challenged. The patient seemed to regard this as rather ridiculous, as, after all, she was perfectly well aware that her guilt was in some sense ‘irrational’, but nevertheless, she wished to talk about it.
At the end of this second session, I raised with my supervisor the possibility that CBT was not the best option for this patient. Again, I was told that it was the only ‘scientific’ treatment. (This was before the days of mindfulness being fashionable). My supervisor assured me that the patient would soon see the error of her ways, and that her ‘homework’ should be checked for compliance and completion.
By the third session, it was clear that the young woman had had enough of homework, and of refuting the propositions she carried in her head. Because of the necessity of ‘selling’ CBT itself in the sessions, explaining the homework, etc – typical features of this treatment – she had not yet actually discussed any of the sexual behaviour that caused her so much trouble. Needless to say, she did not return for a fourth appointment. My supervisor was very clear in assigning the cause of this ‘non-compliance’ to the patient.
By this time, I was enrolled in a Doctorate, and undertaking my first student placement. Despite involving long hours and being totally unpaid, I had had to compete with other candidates to get a 6-week position at one of Melbourne’s better private psychiatric facilities. My role was to help in running a range of activity programs for young adults with a range of diagnoses.
Along with the other staff and students, I used the intervals between program sessions for lunch, case notes, and the like. On one occasion, on a wintry mid-morning, I confessed my eagerness to go outside for a coffee and a cigarette. The staff – one of whom was my supervisor – looked at me with obvious horror and contempt. It was as if I’d said I was ducking out to commit a serious crime. Smoking was for the ‘clients’ only, and I was told that there was no place for staff or students to smoke, except perhaps, around the block. If I was tired, I should try ‘sleep hygiene’. I should avoid coffee, and stick to water. I should do yoga.
To be sure, smoking is not a great idea when it comes to health, but my impression was that, in this case, it was not just a matter of it being unhealthy, but of being ‘maladaptive’.
These two anecdotes are not especially interesting in themselves, and perhaps every person who has trained in the psy-disciplines has had similar experiences. What I would like to draw attention to is the superegoic inflection that coloured both of these situations. In both cases, supposedly scientific formulations and approaches were a thinly disguised cover for moral judgements (about the ‘irrationality’ of the young woman patient, or about my own pathology at that time for caffeine and nicotine). Officially, psychologists may place every phenomenon on a spectrum, but in practice, there is (often) an aggressively-enforced delineation between ‘us’, the exemplars of ‘wellbeing’, and ‘them’, the sick ones. (Never mind that the ‘wellbeing’ at stake in these institutions, which is generally beyond any questioning, always has a habit of resembling Protestant heaven).
I said that all this had something to do with the superego, a claim which calls for some explanation. It isn’t difficult to discern a certain puritanism in the attitude conveyed by my superiors. Purity in thoughts – no distorted cognitions, thank you – and purity in enjoyment. Purity of essence. Yes to pleasant, positive activities like drinking water and doing yoga, no to vices as a mode of jouissance. Pathology, for the puritanical clinician, is a misdirection of the drives, usually arising from the alleged ignorance of the subject about his own best interests, on which the puritan is all-too-eager to educate him.
What then of the puritan’s drives? Lacking an outlet in pathogenic ideas and activities, do they simply disappear, leaving a chaste aura of ‘wellbeing’? On the contrary, the drives clearly continue, but in other forms. So the evangelist of wellbeing develops a jouissance of sacrifice or renunciation, for instance, or becomes savagely critical of themselves and others. We can understand these practices to sometimes constitute symptoms in the psychoanalytic sense, in that a symptom is that which brings jouissance. It should be stressed, however, that, as symptoms, they are more congenial to the prevailing ideology than the unproductive pathologies, and are therefore symptoms which are much less likely to be recognised as such.
This may be one of the reasons why, for instance, suicidality is much higher in doctors and nurses than in the general community, both in Australia and elsewhere. It is not easy to ask for help when the problems requiring help are all too simply and violently pathologised, dismissed as ignorant or maladaptive, indicative of defective ‘traits’. The helping professional is in the grotesque and hypocritical of bind of having to directively treat the sick for their weaknesses whilst desperately covering their own. The better the cover, the more ‘professional’ the professional.
Introspection is of little benefit to the psychologist, in my opinion. First, as an analyst can tell you, analysis is self-analysis, to be sure, but it needs to be spoken before an Other in order to be done properly. Second, the conceptual apparatus of mainstream psychology is particularly deleterious to attempts at self-understanding. So often, suffering is dissociated from cause, and instead correlated with faculties and ‘factors’, all of which elide both personal subjective implication, and specific historical determinants. Psychological ‘health’ is implicitly connected to ideals of efficiency, and discipline of body and mind. One can speak of ‘attachments’, but not of love; of ‘’dysphoria’, but not suffering; of ‘motivation’, but not desire. Thus, in addition to the usual list of scarcely bearable features of existence that amount to the common lot, the psy-practitioner is also asked to think through a periodic table of pseudo-scientific, ideologically-loaded conceptual elements that only augment alienation and obfuscation.
The drives will have their way, however, and whilst each drive aims at a certain enjoyment, it also is the bearer of that which Freud termed the death instinct. The drives would seem to be operative in standard psy-practice. Consider, for instance, the now-commonplace exercise of inculcating the sick with the imperative to self-report, not via discourse, but through the mediation of apps, ‘homework’, and the like. In psychoanalytic terms, it should be clear that in these cases, the clinician is working through the scopic drive, instituting 24/7 surveillance (and discipline) on the one who is suffering. It is this use of the drive – setting up the ideals of coercive biopower – that can be called superegoic. Quite rightly, Bifo calls this kind of biopower ‘thanatological’, yet it currently maintains a strong following all the same. This intimacy between destruction and healing is maintained closely in contemporary ‘health’ professions.
The superego is not, as is sometimes believed, simply an internalisation of one’s parents. It is rather the internalisation of one’s parents’ superegos. It is one’s parents at their most ferocious and obscene, and, as the voice of the drives, the superego itself is ferocious and obscene. Superego diffused into biopower is one way for drives to find expression in a manner that is (somewhat) socially acceptable, but the superego is a doubled-edged sword. Those who live by it also perish by it. That part isn’t in the psychology textbooks.
Quis custodiet ipsos custodes? This is where psychoanalysis is essential. It is not a matter of psychoanalysis being the super-superego to the superegos of psychology. Psychoanalysis cannot further purify the puritanical, and can disrupt the prevailing biopolitics to but a limited extent. What it can do, however, is call into question. As my Facebook friend, Richard Klein, is fond of saying – the psychoanalyst does more than the scientist in the sense that, rather than merely implementing one technique or another, the analyst calls his or her own desire into question, radically and repeatedly. In this sense, it is a praxis more rigorous – in terms of ethics and epistemology – than any ‘scientific’ application of technology.
It is this desire – a concept quite distinct from demand and the drives – that must be called into question for any psychologist worthy of the name. It is a matter of urgency that the psy-practitioner asks themselves what it is that they want, from life and from praxis. There is no possibility of a ‘training’ or ‘didactic’ analysis – psychologists and therapists have lack, like anybody else; jouissance, like anybody else; and hence, symptoms, like anybody else.
For the psychologist to imagine that his or her practice is one of unalloyed altruism, that it is the execution of the ‘scientific’ technique, is already to be ensnared in a narcissistic fiction, in which the ‘clients’ are mere fantasmatic props being used for the clinician’s enjoyment.
Psychology has problems, and psychologists too have problems. Symptoms, one could say. Yet here, as ever, to directly attempt to abolish a symptom is to lapse into a master’s discourse. In a master’s discourse, it is always a matter of saying – “See things my way, do what I tell you, then you will be better”. This approach is fairly standard in medicine, but it is nothing like psychoanalysis.
The psychoanalyst’s routine is therapeutic. His business is with the symptom as what has to be cured…Today, after Lacan, the psychoanalyst likes to give himself airs. He likes to be difficult. “Cure! Did you say cure!”
The fact that the psychoanalyst can question the notion of the cure changes nothing. He tackles the symptom, in his practice, as something that must be eliminated, got rid of, and that’s what people come for. If somebody goes to see a psychoanalyst for the sake of knowledge and not to get rid of a symptom it is not very certain that his demand can be received.
These are the words of the psychoanalyst Jacques-Alain Miller. It is in the spirit of these words that I argue that the psychologist needs a psychoanalysis – not for knowledge – but for treatment of symptoms, and that, without which, his or her practice is but a make-believe of objects, a playing doctor, for his or her own gratification. More broadly, one can identify at least two purposes of psychoanalysis, which correspond roughly to the ‘early’ and ‘late’ work of Lacan respectively. On the one hand, there is the interpretation of desire, with its fantasies, lures and displacements. On the other, there is the nomination of jouissance, which can be found in places which are, for mainstream psychology, at least, among the most unlikely. Both purposes are essential for anybody who wishes to have a clinic oriented around a talking cure.
Of course, there are no definite ‘outcomes’, and you may not hit your KPIs. All this – not to mention speaking freely itself – can be a source of anxiety. Nonetheless, anxiety is a small price to pay for a practice – and a life – destitute of the coercive fantasies that so entrap human subjects of the 21st Century.
Miller, J-A. (2012). Psychoanalysis, the city and communities. (Trans. P. Dravers). Psychoanalytical Notebooks, 24.