From Psychoanalytical Notebooks 4, 2000 : Psychiatry and Psychoanalysis

CONTRAINDICATIONS TO PSYCHOANALYTICAL TREATMENT

Jacques-Alain Miller

            Phenomena of all kinds manifest themselves in the course of an analysis, which have the effect of posing an obstacle to the treatment. As Diana Kamienny recalled, since Freud it is customary to isolate these phenomena which pose an obstacle to the treatment as resistances.

            In the same vein, and through a passage-to-the-limit, one cannot but question oneself about those resistances which, posing such an effective obstacle to the analytic treatment, render it impossible. This is the limit case of resistance. Hence the question of contraindications, raised by this Symposium, which is the question of cases in which psychoanalysis is impossible. There are cases in which psychoanalysis is impossible.

            Let’s admit then that there are structures, or at least types of symptoms, which are impervious to the analytical treatment, and where psychoanalysis is inopportune, inefficient, even harmful.

            But if we admit that there are cases of impossible analysis, how do we know it beforehand?   How can we anticipate it? What are the criteria allowing us to formulate a prognosis of impossible analysis?

            There was a time when psychoanalysts tried to define such criteria, and to detail what one used to call, above all in English, the conditions of analysability, conditions which make a subject analysable. Transference was amongst them without a doubt, but also the capacity to analyse transference. Prevalence of the rule was required, without which there would be no free association, no regular meetings, no punctuality of payments, no acceptance of the interruption of sessions, weekends, holidays. In short, if the rule did not prevail the setting would not be respected. But the rule was not to be ritualised either, for severe obsessional neurosis does not let itself be easily mobilised. Thirdly, there were conditions concerning age: in short, neither too young nor too old. And finally, there were conditions of culture, a sufficient mastery of language, of the ‘verbal material’, as one used to say, etc.

            The lists are long and varied. I was able to refresh my memory on the topic thanks to the collection of classical texts given to me by the [hospital] Service of Françoise Gorog, and in particular by Diana Kamienny. The lists of these conditions converge upon an identical and major point: the strength of the ego [moi].

            For the analysts who compiled these lists, the strength of the ego is what conditioned the very possibility of analytical treatment. In the absence of an ego that would be sufficiently strong not to be submerged by anguish and the drives, sufficiently strong to accommodate itself to common reality — psychoanalysis is impossible.

            This was not without paradox, as this strength of the ego, to which in the end all the conditions of analysability belonged, is also what was expected as a result from the analysis itself. Thus, in a way one can say that the consideration of these contraindications and indications led up to the fact that the final stage expected from analysis, is in some way already demanded at the beginning, the difference being only a question of degree. The strong ego expected from analysis was in some way demanded in a reduced form, although only a little less, at the very beginning of the treatment.

All the same, a clinical selection takes place according to this criterion of the strength of the ego. In the end, the selection I found most convincing and worthwhile is that presented by Edward Glover in 1954, according to which there is a positive indication for psychoanalysis in cases of hysteria, pure or ‘mixed’ — namely, including some obsessional elements ­—, as well as in pathologies which present sexual, social or conjugal disorders when they amount to neurotic states.

            There would be a contraindication to psychoanalysis in cases of pure psychosis, psychotic character, severe mental illness.

            One can situate between these two groups cases fairly accessible to the treatment, namely: moderately organised obsessional neurosis, sexual perversions before the age of forty, alcoholism, and drug addictions which have a neurotic basis.

            It is a firm classification. Amongst the best, it finds its theoretical foundation in the classification of pathologies upon the axis of development where the Freudian phases are ordered chronologically. Thus psychiatric symptoms are brought back to a point of fixation situated with precision on this chronological axis. They are supposed to carry the mark, the hallmark — Glover says the hole mark [English in the original.] — of this point of fixation, while character disorders are not identifiable in the same way, and the sexual disorders even less.

            To put it in classical terms, we have three groups of prognosis, conceived in the end to guide the psychiatrist. In fact, the Glover article I am referring to here appeared in The British Journal of Psychiatry. And one has not really done anything better since.

            However, one cannot, at the same time, help feeling that this approach has since then become obsolete and void. There is a very simple reason for that: this approach is organised according to a conception of the psychoanalytical treatment as ‘pure psychoanalysis’.

            What are we to understand here by ‘pure psychoanalysis’? It is psychoanalysis conceived as a treatment of a paramedical order, which aims at a cure, or even ‘normality’, and proceeds by way of an average of five sessions per week, and as Glover says, ‘for a period of one and a half to two years’.

            Such is what was required for a treatment of ‘pure psychoanalysis’, according to which one could arrange these indications and contraindications.

            Since 1954 however, if one is to take this date as a landmark, the dynamic proper to the psychoanalytical experience has evidently exceeded the Gloverian framework. And Glover himself made the following reservation: “the indications of psychoanalysis should not have to be determined solely by prognosis”. With this proposition, this division introduced between prognosis and indication, the whole dynamic of the analytical practice since 1954 rushes in.

            Everything happens as if the practice invented by Freud had been animated by a dynamic which irresistibly exceeded the framework of indications for analysis, so much so that it took away what appears to have been a therapeutic barrier supposed to contain the very power of this practice.

            Since we are on the topic of anticipation, let us say that Freud had anticipated this, since he elected to refuse entrusting the future of his discovery to the medical profession.

            Let us remark that the medical framing of psychoanalysis was evaded from the very beginning by the psychoanalysts themselves, and this as soon as the passage through analysis became an obligation for the analyst’s formation. A properly didactic dimension was thus introduced which already allowed psychoanalysis to escape its strictly therapeutic significance. At the same time, we must note that, through no conspiracy nor through any special, particular charisma nor through any cultural aberration of one country or another, psychoanalysis finds itself de facto invested as a practice of truth, and even perhaps as the most distinguished contemporary practice of what Michel Foucault called the ‘care of the self’.

            To put it in Freudian terms, psychoanalysis has been the object of a sublimation which took it very far from the register of therapeutic indication.

            From whence it must be noted that the very sense of what one used to call psychoanalytic treatment has changed.

            We can even say that the word ‘treatment’ has ceased to exhaust the signification attributed to the practice of psychoanalysis, a fact acknowledged by Lacan when as early as the 50s he replaced it with the term of psychoanalytical ‘experience’.

            One has shifted from a ‘treatment’, which could be ‘indicated’ or ‘contraindicated’ through the evaluation conducted by an other — a scholar, a sage, an expert — to the vital, even ‘existential’ ‘experience’, which the subject himself can ‘desire’ or not, and even risk as a true ‘subjective adventure’.

            What comes to the fore is no longer the indication but the demand which a subject — one no longer says ‘patient’ — presents to the psychoanalyst, and the authenticity, to be verified, of the desire which inhabits this demand.

            Likewise, for a psychoanalyst to refuse analysis to a subject who demands it no longer has the signification of ‘contraindication’ today. The demand is indeed supported by a certain kind of implicit ‘right’, which one could even call a ‘right to psychoanalysis’ inscribed in the contemporary ‘quest for sense’, which is manifest enough to have turned into a political slogan.

            From then on, the psychoanalyst becomes the instrument of the ‘right-to-sense’, which the patients are not the only ones to recognise, since therapists themselves willingly admit that a given medicinal treatment calls for a semantic complement, a complement of sense.

            If we are to look back on the forty years which have gone by since the Gloverian selection of indications and contraindications to psychoanalysis, there is yet another feeling we cannot defend ourselves against: that the psychoanalyst has become ineluctably separated from psychoanalysis, from what one used to call ‘pure psychoanalysis’.

            ‘Pure psychoanalysis’ has become increasingly reserved for the very formation of the analyst, while the practice of analyst who has been formed in this way distances itself evermore from the conditions of his own formation.

            Could we not speak here of a disjunction between the psychoanalyst and psychoanalysis?

            Freud invented an unprecedented type of subject, formed, no doubt, to interpret the unconscious and support transference, but also, by this very fact, able to support the repetition-automatism of the symptom, and to incarnate the object of the drive.

            This psychoanalyst-object is from then on available — available, as one says, on the market — to lend himself to uses very different from the one conceived under the term ‘pure psychoanalysis’

            ‘Pure psychoanalysis’ is thus only one of the uses to which the analyst lends himself. And this is the new face of the indication of psychoanalysis. It is less about anticipating whether the nature of the problem is ‘accessible’ to psychoanalysis, than about knowing whether the encounter with an analyst may be useful or not, produce good or evil.

            Let us avoid philosophising on good and evil. The encounter with an analyst generally produces good.

            The psychoanalyst-object is surprisingly versatile, receptive and, if I may say so, multi-functional.

            Here, he loosens the ideal identifications the exigencies of which besiege the subject. And here, where the ego is weak, he extracts from the statements [dits] of the subject the material with which to consolidate a viable organisation. If the sense is blocked up, he articulates it, liquefies it, dialecticises it. If the sense flows non-stop without stopping upon any substantial signification, he introduces stopping points, quilting points, as we sometimes say, which give the subject a supporting armature.

            In short, if the analyst knows how to be an object, to want nothing a priori for the good of the other, to be without prejudice as regards the good use which can be made of him, he will see the register of contraindications shrink surprisingly to the point where the contraindication is decided case by case.

            For that, he must have cultivated his docility to the point where he knows how to occupy the place from which to act for any subject. And what an act it is!

            Here is an analyst, Mr P. He has been seeing a female patient for five years, whom he put on the couch in a reclining position. He places himself in his arm-chair, sitting behind her. She comes regularly three times a week. One could believe it to be a ‘pure psychoanalysis’, although it is two sessions short, apart from the fact that the patient has not shown any signs of change in those five years. She fills out the sessions with a monotonous, disaffected monologue in the course of which she meticulously narrates whatever happens in her existence. When Mr P., analyst, speaks to try out what is commonly called an interpretation, she breaks off, allows him to speak, to finish, then she resumes speaking, ‘as if nothing had happened’, as Mr P. puts it. Short sessions, long sessions, interpretations or interventions, provocations or encouragement — nothing works. Mr P., analyst, is at a loss. He no longer knows why she is there, nor why he is there, who he is and what he does. Nevertheless, he perseveres because he remembers that the patient, before coming to see him, was with a colleague, a psychiatrist, who saw her for almost a year before showing her the door, saying to her: ‘you have nothing to do here’. A suicide attempt followed. Mr P. no longer has any hopes concerning therapeutic changes in the patient, yet he will not show her the door. He still remembers one thing she once told him, a long time ago: ‘to come here is for me a guarantee of not going mad as my father did’. This suffices for him — of course it does, as he has nothing else.

            Is this pure psychoanalysis? Certainly not. Is this a treatment? It is not certain. Is it experience? It is not to be ruled out but nothing indicates it. But who, except for an analyst, would take up this role in this game? Here, he lends himself to incarnate an object around which the statements of a patient, as vain as they may be, seem to coil, a patient of whom he will doubtless know nothing more.

            With the psychoanalyst-object, psychoanalysis provides the place for a vacuole, a space between parentheses, where, during a restricted time, a patient has the chance of being a subject, that is to say, of lacking-to-be what otherwise identifies him. It is, if you wish, to use Winnicott’s term, a transitional space, a place of pure semblant, which is like an inversion [l’envers] of everyday life, and where the subject is constantly driven back to the birth of sense, to his first babblings. It is a place which welcomes contingency, where necessity loosens its grip, and this is par excellence the site of the possible.

            Even if the subject does not do anything with it, the session is nonetheless the site of the possible where, although there may be no change, a shift is always possible.

            This is why this encounter with the analyst may prove priceless for the subject, even though it may be a case of impossible psychoanalysis.

            The disjunction between the analyst and psychoanalysis, that between the analyst’s formation and the analyst’s practice, is today a fact.

            The dissolution of the old framework of indications and contraindications has also been accomplished.

            Then why not formulate, through a passage-to-the-limit, that ‘there are no contraindications to psychoanalysis’. Let us add, ‘there are’, as Jean-Jacques Gorog remarked to me during the preceding break, ‘no a priori contraindications to psychoanalysis’. Let’s say that there are no contraindications to the encounter with the psychoanalyst.

In passing, this is the radical consequence of the ‘right-to-sense’, the right to be subject to sense.

            No doubt, this encounter often has an experimental character. Let us see what sense this subject could derive from his symptom, and if, by extracting sense, something of jouissance would come too, that is to say something of the unconscious drive-satisfaction that one may suppose him to find in his symptom.

            This indicates at least one condition — the condition of the symptom. There must be an analytical symptom, and a suffering of the symptom: that this jouissance of the symptom presents itself in the guise of displeasure. And this already suffices to imply transference.

            No doubt, this still does not say what must be done with the symptom.

            This is to say nothing of the objections that the analyst, this time as subject, can raise from his side.

J.-A. Miller’s response to the questions of the audience

I am not proposing that a right to psychoanalysis be inscribed amongst the rights of man. But I am asking whether everything is not happening as if a certain right-to-sense had been widely recognised and whether today, the fact of refusing analysis, or of telling someone that psychoanalysis is not for him, has the same sense as it did forty years ago.

            In consulting these archives, it is evident that it no longer has the same sense today, and even the term ‘psychoanalytical treatment’, which appears in the title of the Symposium, is somewhat outmoded, and not by fiat or decision. We can observe how language has changed, how practices have changed.

            I evoked the dynamics of practice. Freud’s sons, as one used to say, have been taken up in the roll of a wave [roulés dans la vague], an extremely powerful wave which cut the analyst loose from the ‘cure-type’. Through diverse, glorious or mediocre ways, in the end a use of the analyst has imposed itself, which we must assume or account for.

            We speak a lot about ethics. Where is the ethics of the analyst? Would it have been to uphold obstinately that he must only serve ‘pure psychoanalysis’, and that the other uses one makes of him are deviant, derivative, and which in the end depreciate psychoanalysis? For example, Lacan founded his School ‘to restore the cutting edge to the Freudian truth’ and ‘to denounce the deviations and compromises’ of psychoanalysis. After all, such a position could have been deduced from this. Well, it is most certainly not the one that has been deduced. The students of Lacan, like the others, accepted the uses made of them, which are not those that were prescribed at the beginning, and which explain at the same time the extension and the feeling of dilution of psychoanalysis that one can observe.

It is with irony that I speak here of the ‘right to psychoanalysis’.

            What remains as a question is this: ‘where is the ethics of the analyst?’ Is it to be situated in his opportunism? For the analysts were opportunists. They took the places that were opened for them. Is it in this opportunism or in a purism, which is today completely outdated, or which only finds its place in the register of the analyst’s formation?

Translated by Bogdan Wolf

Copyright © Jacques-Alain Miller 2003. This text from the website of the London Society of the NLS, at http://www.londonsociety-nls.org.uk. Permission to use material from this site must be sought from the LS-NLS. All rights reserved. Please include this portion of the text in any printed version of this paper.

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