Tag: medicine

The transparent sheet that separates us from our patients (and madness)

“Lets make it more than impersonal”

Who controls the content of the ideologically commanded medical consultation? Is it Public Health, The State, Business, or The Law? And what of the agenda and caritas? I’ve a feeling that it has  been getting harder and harder to discern much ‘caritas’ in consultations (those commanded by State Medicine under Capitalism) for the Heroin addict, or for the Patient-of-Screening.

Its hard to imagine anything much further removed from Freud’s consulting couch than the average GP consultation, with its eye contact, stethoscopes and prescription pads. If we, for the moment, take seriously the issue of the words we speak and what they mean, we can turn to Lacan’s mirror stage. We can all feel uncomfortable about the innuendoes, silences and mis-communications that pepper everyday ‘talk’ – but why should it be so hard to understand what the other person means? Why don’t they and their words seem to mean exactly what they say?

For Lacan, during the Oedipal phase, our ‘inauguration into linguistic consciousness’ (Judith Ehrer-Gerwich) is closely related to the trauma of an enforced realisation, in the mirror stage at about eighteen months old, of our superfluousness to our mother-figure, of no longer being the sole object of her desire. Language through words become the means of our demand for recognition, our quest for completeness. But these words we speak are constituted by a unsymbolisable trauma, our Real, a division that is what we are, divided within ourselves by a traumatic separation of our conscious language from our unconscious. Our unconscious is both ‘external’ to us and at the same time most ‘intimate’. Lacan’s describes this as ‘extimate’. The act of speaking itself is always re-dividing the speaker since the I that is spoken of can never be identical and simultaneous with the I that is speaking. I’ve laboured this point a bit, because its important, really interesting and hard to understand, let alone explain.

But why should this interest a medical doctor? And what of Freud’s couch? And how transparent is the sheet between doctor and patient – the wall of mi-recognition that is the truth of medicine?

If language is the ‘wall’ between analyst and analysand, the necessary mediation and mechanism of representation, and speech is both sensed and needs to be made sense of, then what use can the participants in a ‘conversation’ make of it.

Adam Philips, a psychotherapist and writer at a recent seminar, talking about some of his writings, including an essay: “Lets make it impersonal’, opened the debate by suggesting people at the seminar should feel free to a) be silent, c) to be incoherent and c) to free-associate. For, he suggested, it is sometimes the most incoherent free association that is the most striking. It felt like a luxury, possibly even therapeutic, to be invited to be freely incoherent. It is not often a medical doctor suggests the same to his client (always already the ‘patient’, the subject-of-medicine’, but not the ‘analysand’) in the medical consultation.

Through free association, the analyst’s role becomes ambiguous, a background role in a sense, there to prompt the analysand into a productive surprise at his own internal contradictions and e.g. slips of the tongue. There is a necessary distance, it is impersonal. It is argued, I think, that being too personal, communicating in such a way that gives the impression that can interpret, and that you known the hidden meaning of what the client is saying, would inhibit the client’s responses to his own unconscious, encourage the client to persevere with the script he is most comfortable with, his imaginary symbolic world (and avoiding his Real world), and may reinforce a tendency for the client to ‘look up to’ the analyst, or doctor, as the expert, with the ‘ medical gaze’ described by Foucault, he who knows the secret ‘things to be known’. Adam Philips argues, as well, that in the medical consultation, there are benefits in not being too personal, since maintaining a distance will allow the (now) ‘patient’ to bring forth their own script unencumbered by the doctors probable mis-recognitions and misleading stray alleyways. Keep a distance and let the patient tell their own story, start the consultation by keeping your (the doctor’s) mouth shut and the ‘patient’ will reveal all.

However, and here is the turning point in this short essay, at last. I believe there are consultations that are set up as ideologically commanded events, the ideology being Modern Medicine under Capitalism with its injunction: “Be Normal” under which the commanded events are those that are initiated by the State and other Capitalist Corporations. The ideology is hegemonic, it promises that which it presupposes we already desire, whether it is death avoidance, a marque of first class ‘ill health’, or some other ‘consumable’.

So, to be clear, here I am not referring to the consultation where the client decides to go to the doctor because they have a problem. Here, instead I am referring to consultations where the individual has been invited to attend, or has to attend to continue medication. Transformed into a patient by diagnostic ‘naming’ processes in which so called risk factors have been transformed into dis-ease, or where so called normality is forbidden, wherein normality is itself a risk factor as in attempts to ‘catch it early’ in cancer screening programmes. I am also talking about, for example, the consultations in addiction services where addicts tend to be prescribed their oral substitution treatment (OSTs, Methadone or Buprenorphine), and where they sometimes engage in psycho-social-interventions and motivational interviewing.

In my experience the consultations can be dominated by a script that seems to have been learnt by the client, and a script encouraged by the clinic. A script that is centred on some jargon like ‘recovery’ or ‘low threshold prescribing’, etc; dominated by the visible-safety of prescribing, the number of days of the week the client must be physically observed taking their OST, and/or the number of days of the week the client has to collect their prescription from the pharmacy. Decisions on these points are in the gift of the prescriber, and depends upon a professionally normalised, guideline and policy regulated, perception of the client’s (and others) risks of coming to harm through overdose, which in part depends upon their drug taking history and the evidence from urine testing. This is a highly regulatory environment, within which it is difficult to create space for other non-regulatory scripts.

I do wonder how often the addiction consultation remains within an impersonal, regulatory framework, dominated by risk management. How often the client embarks upon a speech intended to reassure the doctor about risk to obtain relaxed prescribing measures. Or how often a wall of silence pervades the air as the client knows to try again is pointless as he has tried and failed so often before. Or how often the doctor dominates with questions about risk.

Whilst it is essential to manage carefully the risks of prescribing highly dangerous medications, medications that have been directly implicated in deaths through overdose, is it possible to be more than this impersonal? Is it possible to stand away from regulation and safety, not to become more personal but to become more than just impersonally interrogative? To encourage some free association and incoherency, to observe for contradictions and ‘slips of the tongue’ – to provoke ambiguously, to suggest the client tries a spell on the couch?

Whilst impersonal communication styles can be informative, in the same way that a YES/NO answer questionnaire can be informative; and whilst that can even provide space for a ‘patient’ (with a problem) to perform the script they had planned all along, if, on the other hand the script is authored primarily by the State or corporate industry, as in much preventive public health medicine and addiction clinics, then the doctor/analyst has a role to subvert the script to provide space for the client, to provide opportunity for the client to challenge the script and themselves, if they wish. Is it worth breaking down the regulatory iron wall of communication and replace it with Freud and Lacan’s leaky wall designed to allow the analysand to speak with him/herself, to explore his relationship with his desire, that nature of the object of his/her desire, and to become the analyst.

What does the client say about his/her relationship with the drugs? What do they say about why they keep coming to the clinic?

The ‘Abstinence’ rhetoric and the Pathological Heroin-Thieves

I argue here that Addiction Services that are abstinence focussed inhibit therapeutic change.

A broader perspective needs to take into account the client’s relationship with the culture of addiction as one possibility for what is an essential socialisation, but a possibility open to alternatives and change. In other words if the client does move away from the culture of addiction, how can it be replaced by an alternative and does this require some fundamental changes in the client’s sense of their place within the new culture or symbolic network., i.e. a change in subjectivity or neo-subjectivity.

The ‘addict’ can present as an ‘underground hero’, with a degree of ambivalence and ambiguity, with The Prohibition creating jouissance, a sense of hard to symbolise pleasure/excitement derived even from pain, from the act of doing something prohibited, officially illegal. This creates various not exclusive possibilities: the ‘need’ to use to prevent withdrawal symptoms and the nature of the possible symbolic relationship(s) that the addict has with the drug itself,

This sets up two extremes neither ever wholly and solely true but both always materially effective, namely two gendered possibilities. The psychoanalyst Lacan describes the individuals power relation to an ideology as a gendered ‘sexuation’ that is not bound to a biological sex. The masculine is wholly enflamed by the symbolic structures but feels powerless and strives to have power by feminising the ‘Other’. The feminine is not wholly enflamed by the symbolic and is ‘not-all’ an object of mystery for the masculine, and who feels a desire to be of service to the masculine. The gendered relationships her firstly, is with the drug as an object of value for the addict, “I enjoy it….” or secondly, the addict as an object of value for and working for the drug: “it’s holding me back…”. The relationship with the substance misuse service is judicially determined by the abstinence rhetoric and feminises the client as external to (or at least not fully captured by) the symbolic network and pathologised judicially as an ‘addict – criminal or patient’. Alternatively the client can be given gendered options by the service, (which is a Lacanian psychoanalytic approach) to examine the nature of the relationship with the drug and the service. The relationship with the addiction is one with a socialised intersubjective culture, and also one with its own phantasmic structure and relationship with an Other, a Look (Sartre), as part of a scene as if observed. The behaviour may be perceived as pleasing for the Other accruing admiring praise, or it could be perceived as creating pain anxiety or anguish for the Other. The behaviour is part of a human drive emerging from the constitution of subjectivity as it emerges through language as either a masculine complete submission to the symbolic resulting in a powerlessness, but ‘with its escape clause’, a fantasy that there is an Other, the primal father who does have all the power; or a feminine emergence from the oedipal process as not completely contained within the symbolic,  a part has escaped, so that she does not fully exist within the symbolic and is structured against the masculine for whom (?stereotypically) she may desire to be an object of value.

Clinically an early key issue is the nature of the client’s relationship with the addiction, what is addiction? are they ‘addicted’?, is the drug of value to them? e.g. do they control the drug (and why?), or, are they of value to the drug, does it control them? An issue is whether losing the addiction will lead to its replacement with a different object of ‘addiction’. Is the relationship hystericised (feminine, repressed and disavowed, which is common) or is it perverted, the role played of the ‘underground hero’, the masculine role of the Father of Enjoyment who knows the things to be known but who may also paradoxically be acting out rage against his or own femininity, by feminising others. Is the aim of analysis to disrupt or to stabilise the client within the symbolic network or culture of addiction.

The ethos of the service may demonise the addict as the Heroin-Thief, who has metaphorically stolen our enjoyment, stolen our Heroin, who must pay us back, by providing us with their alway assumed to be heroin infused urine, so that, in the process we feel a libidinal gratification.

The current funding indicators and official policy promote abstinence, investing the service with a gendered masculine role in relation to the clients, this will either reinforce the hysteric, or set up conflict with the pervert; in either case it forecloses possibilities for change. This abstinence culture creates several roles for the clinician:  a role that is seen by some clients as a supportive ‘dealer’ providing something for nothing, or as an insurance salesman providing something for nothing, and/or as a policemen simply interfering with the addicts smooth symbolic functioning. None of these roles permits effective exploration of possibilities for changes in the client’s relationship with the addiction culture/society. Effective work with clients, at least work capable of promoting change if it is desired by the client should therefore avoid an abstinence driven culture, and focus more on exploring the client’s signification in relation to his addiction culture.

Misrecognition is Medicine’s Truth

The apogee of Modern Medicine is the universality of Dis-Ease. Achieved by the injunction: “Be Normal!”. Which paradoxically forbids normality; and is the injunction of a masculine phallocentric Medical Establishment.

If for now we Agee that Medical Perverts exist – who have a psychical structure of ‘perversion’ with the object of their medical practice. Which is to say those who are driven to constantly re-break and re-make their own Great Law, behave as Obscene Fathers, as the Primal phantasmatic Father come to life. Those such as paediatricians Meadow and Southall responsible for the wrongful surveillance of and imprisonment of mothers accusing them wrongly of murdering their babies. Creating a dis-ease to fulfil their libidinal needs, where no dis-ease exists : Munchausen Syndrome By Proxy. If we agree these Perverted Psyches function we can ask: why do they?

Are they the inevitable result of the present antagonisms within the neurotic (majority) structure of the dominant ideology (which it is the role of the critical intellectual to keep open) and which is the aporia of the zero point between meaning and non meaning, arising within Medicine within a framework enclosed by the normality-pathology opposition. This is like the Subject-Object opposition – the result of diagnostic processes being applied to the healthy asymptomatic individual – a process otherwise known as screening; the apparently harmless innocent (and profitable for some) ‘health check’. A process which abhors the vacuum of knowledge which is not-knowing: why do cot deaths occur? Why do cancers occur? Why do people become Crack, Heroin or Alcohol addicts? Why do people become depressed? These questions all become sites of struggle and the sites of creation of diseases, overdiagnosis, medicalisation, the manufacture of the de novo patient and medical hegemony.

The process of diagnosis for the asymptomatic individual does two things, firstly it confronts Medicine with the uninterpretable tissue representation of an ‘unknown’ anticipated future and secondly and conversely it a performs a misrecognition as it names the tissue to provide an assertion of ‘known’ anticipated certainty that transforms the individual into a now reified patient. The misrecognition in diagnosis reveals the structurally unavailable Truth – the encounter with the zero point of just ‘not knowing’ results in the misrecognition. It is possible, since the representation can never be adequate to the thing in itself, that this produces a libidinally charged remainder, an ineffable left over sufficient to excite further creation – the creation of the horror of the phantasmagorical apparition that is the Medical Pervert, the Obscene Father, a phantasm become real. Only visible because of the materially concrete actions and transgressive behaviours that break The Law (of the Medical Establishment resulting in a public defrocking by the GMC), whilst exposing precisely that which has secretly been sustaining that same Law all along. The Medical Pervert for example publicly stereotypes the always already guilty murdering-mother, and creates a new syndrome to match the MSBP; a bit like saying serial murderers all suffer from a medical syndrome, a fatal assault by proxy syndrome.

Across Medical practice the population at large is named as universally dis-ease ridden, this is the apogee of Modern Medicine.

Q. Is the pervert constantly looking himself in the eye and seeing Evil, with a gaze that directed outwards seeks out and names Evil In an excluded other, such as the murdering-mother?
Or do we all have a tendency to do this, part of our cultural prejudiced heritage?

The Sublime Object of Medicine

In the latest addition of the BMJ Margaret McCartney (BMJ 2015;350:h439) asks if : “All knowledge is Power”, and she critiques the diagnostic uses of genomic industries such as ’23andme’.  I think the converse is true and reveals a truth behind medicalisation.

“All Power is through the illusion of knowledge”

Medicalisation and the abuse of ‘diagnosis’ (using healthy people to create disease products for a capitalised Modern Medicine) is ensured by Medicine’s insistence upon ‘knowledge’ (and a consequent disavowal of ever not-knowing). This requires a ‘blindness’ to ‘not-knowing’ e.g. the inability to not-know or a blindness to the forbidden acknowledgement that the doctor simply does not know what a given test result means (the classic example is the borderline tissue representations in breast biopsy samples) – or even that a particular test might produce an uninterpretable tissue representation.

The ‘blindness’ to not knowing is the result of the way Power operates through the discourses through which individuals and the various Establishments (including Modern Medicine) communicate. To be a Medical Bureaucrat, a Doctor, Nurse, or Patient is to be a Subject-of-Medical-Science, living in a kind of dream world where to be Healthy is paradoxically forbidden. The Power operates because of our constant individual desire to a) find ‘love’ (to find the ultimate solution to the void within each of us) and b) in a magical way, have faith in a Big Other, who we imagine, guarantees that love. A faith that guarantees material behaviours that ensures our contribution to the continuation of the illusion and our blindness. How else can we explain why good people do such dangerous things?

How else can we explain what is likely to be a continued exponential growth in levels of medicalisation and the abuse of the diagnostic process on the healthy. What we can be sure of is that the continued appeal to rationality, transparency and science, eg more shared decision making and use of things like Subjective Expected Utility Analysis etc, will only perpetuate the particular problem of the medicalisation of the healthy, precisely because it perpetuates the illusory blindness to not knowing. If a test is likely to throw up an uninterpretable result and provoke a coerced medicalisation involving harms for sure and no known benefits, then why do it? The classic slogan that appeals to our libidinal desires is “Catch it Early” – its Power is in its Promise of All Knowledge. Medicine is making objects of the individual and treats the individual as if they are a thief, someone who has stolen Medicine’s enjoyment,stolen Medicine’s Sublime Object, an object that is always a mystery but manifests itself in the tissue representations brought forth by ever more deeply penetrating technologies.