PsychoanalysisLacan Volume 2
Papers
How to swallow the medication?
Éric Laurent
How do we swallow medication within the discourse of psychoanalysis? How do we swallow it when psychoanalytic discourse came to light in a field with few medications available, which were not very effective, and which had only minor consequences?
For a long time, the relation of psychoanalysis to medication was situated as a relation of exteriority. Freud had, however, known during his lifetime, towards the end of his life, a first therapeutic revolution. In the 1930s shock therapies, derived from new discoveries about the nervous system, were applied to the psychoses. Electroshock and shock by diabetic coma perfected by the Viennese Manfred Sakel were tested in this field. Freud himself had Joseph Wortis in training analysis, who introduced Sakel’s methods to the United States. But the therapeutic revolution familiar to us — that of medication — only began at the end of the 1950s. This saw the sudden appearance of Chlorpromazine, which inaugurated the series of neuroleptics. At the beginning of the 1960s, Imipramine was the first in a series of antidepressants. Then came the Benzodiazepines, which, prescribed as anxiolytics, and without any apparent marked secondary effects, made possible a very large distribution of psychotropic medication beyond the categories of psychosis. At the same time we witnessed the generalised use of hypnotics and the rediscovery of the older Lithium. At present, successive“generations” of antidepressants have given medication the definitive status of a perishable scientific object. This transient temporal status alone confers a dignity on the objects produced by science. There are generations of antidepressants as there are generations of computers.
We are now immersed in medication. Medication is omnipresent in our field. It overturns clinical practice. It defines ideals of efficacy, transforms institutions of care, overcomes tradition and master-signifiers. It is the object of neurotic demands, psychotic exigencies, and perverse uses. It is the object of persecution and rejection. It is established, spreads, and is very much at home in our field in particular. Is it our master?
If it is ubiquitous, was it not already there before we knew it, if in different forms? The pharmacokinetic nature of the effects of medication is not a matter for our discipline, that’s agreed, but should we nevertheless remain ignorant of the field of medication?
Freud situated the analyst as representative of the father in the transference, as guarantor of the adequacy of words to the drive through psychoanalytic interpretation. Subsequently, in the generation of the 1930s — those who we call the post-Freudians — the psychoanalyst as an object appeared. This came in several versions. For Melanie Klein, genius mother, it appeared as the splendid breast. For Michael Balint, a doctor inspired by the hysterical demand, it was lived as reparative medication; for him, concerned with therapeutic efficacity, following the Hungarian tradition, the psychoanalyst prescribes himself, the hidden medication of the operation. This is the revelation that Balint wanted to convey to general practitioners: “You are the medication!”
We were the panacea, and we didn’t know it. Far from eliminating the dimension of medication, we never left it, we covered it as a whole. We were coextensive with medication. One could give a more modern version of this conception. Transference produces endorphins because it gives the subject pleasure. The latter shoots up in the session.
Was Freud unaware of this satisfaction obtained from the analyst-object? Of the pharmacopoeia of mental illnesses, his epoch knew, above all, the crudest anaesthetics. Freud himself had begun by researching new substances. He is one of the inventors of cocaine. He always underlined the importance of anaesthetics and drugs for a given society. The discontent of civilisation bears witness, deep within his work. But Freud’s true relationship to the agalma of medication is legible in his dream of “Irma’s injection”: it is an epistemic relationship. He seeks the healing power of trimethylamine, and he comes across the formula. No other word but the word, no other letter but the letter, says Lacan, inspired by the Muslim formulation.
It is not medication as an epistemic object, but medication as a libidinal object, that I shall turn to first. It presents itself in four distinct forms: the pharmakon, the placebo, the “surplus life,” the anaesthetic.
I. Libidinal forms of medication
The pharmakon
It is certain that for Freud, as for us, medication presents itself in a way that is inseparable from its underside, as toxic substance. For Freud, as for Plato read by Derrida, the remedy very quickly reveals itself as an evil. In Phaedrus, the god Thamus addresses himself to Thoth, the inventor of writing. This remedy, “by exempting men from exercising their memory, will produce forgetting; they will seek outside, in foreign characters and not from within and thanks to themselves, the means of recollecting…It is not for memory but rather for theprocedure of recollecting that you have found a remedy.”1
“Pharmakon” designates remedy and evil with the same word. Freud had immediately encountered this dimension in not having accurately assessed the dimension of addiction in cocaine. Is this not his first perception of something beyond the pleasure principle? The subject seeks the organism’s homeostasis and well-being — and finds a dreadful routine, ever-increasing doses, habituation.
Medication is always liable to turn into poison. Through habituation and the need for more, it makes a sort of natural automaton of repetition appear in the organism.
As Valéry, who was always treating himself, noted: “the organism itself appreciates the new, becomes sick of the prevailing medication in a few years, and refuses to get better if one does not interest it with novel irritations.”Through its own biological dimension, medication makes appear an aspect of what concerns the transbiological dimension of the unconscious. Medication has strange relations with repetition. If we find it omnipresent in our field, is this not because it is so consonant with this parasite of the organism that is the unconscious?
Is it not at home in the body, by reason of the fault in the organism to which the unconscious testifies? Subjective appetence comes to lodge itself there.
If toxicity introduces us to a “surplus” of medication that interests the subject, there is another dimension of medication that has even more to do with the libido. This is the placebo phenomenon: a biologically ineffective substance can trick the organism for a certain time, in certain affections.
The placebo
The placebo effect is often interpreted as an impure form of suggestion that is inseparable from medication. Experience seems to authorise a subtraction of the subjective dimension, to treat it as an artefact. This is the least interesting way of situating the problem. It destroys the logic hidden there. The placebo has to be treated as an articulation of the true and the false in the body.
To make us appreciate this, François Dagognet first gives a simple matheme (x = a – y), and then comments: “The subtractive proof that authorises the use of the placebo commits the sin of an unfortunate substantivism. It inspires the illusion that the equation (x = a – y) can finally release medication for us in all its nakedness and authenticity” (Dagognet 1964: p. 36). Beyond this illusion, he praises the logical procedure by which one makes use of the false to attain the true. In contrast, he underlines the fact that “what ruins this pharmacometric proof are the erroneous conclusions that the experimenters believe they can draw from it: they imagine they have banished medication’s fringes of indetermination, have uprooted all contingency, and have even driven out the psychotherapeutic clouds that hamper their realism and its clear definitions. The remedy — theme for the philosophy of biological sciences and our leitmotif — is only probability, not at all reality and still less necessity. It draws its power from the possible and the eventual, not at all from the certain….the substantialist error that we will continue to denounce, the false realism re-emerges with the hope for a subtraction that would reveal a therapeutic real with no equivocation….it is impossible to rid these powers of their contingency, of a certain indetermination. If the first remark condemns scepticism without appeal, the second distances ontological faith” (1964: pp. 36-37).
From this perspective, the placebo is not to be used in a subtractive fashion. It simply reveals that all medication is inseparable from a subjective action. An active substance that heals is still more a placebo than the other, the inactive, deceptive placebo: “A substance which heals induces its own faith in itself” (Dagognet 1964). The placebo, in fact, ought to separate us from the substantialist illusion. It is impossible to separate medication from its subject. Biochemical purity is an illusion, but to believe it possible to isolate belief from medication as suggestion is just as illusory.
The surplus of libido
The libidinizing effect of medication, its hope of condensing a “surplus of life,” is present from the first manifestations of the pharmacopoeia. It is drawn not only from plants, but from bodies: “The human and animal world, without exception, enters the apothecary’s shop; almost all the animals find a place in the pharmacopoeia; it is impossible to designate an organ or an excretion that has not been utilised” (Dagognet 1964: p. 74). Let us say that organ transplants were firstly fantasmatic before being useful and effective. The organism attempts to regain its share of living.
In our field, it is with medications of the libido that this dimension is manifest. In this category we can group together what first appeared as an extension of hormones. These are the first “chemical substances whose effect happens at a distance.” The word comes from the Greek ormao, “I excite,” but at a distance. The communicational model in biology that describes the action of a substance in terms of language, message, code, and messenger and receiver, generalised what was first centred on hormones and their immediate “revitalising” aspect. Hormones were the message of life. Medication is thereby designated as a different lure than the placebo. It can deceive the subject in relation to the “feeling of life.” When the subject loses the security of a harmonious relation to this life within himself, when he loses his libidinal body, the antidepressant proves itself capable of sending a deceptive message. By interfering with the message of distress with a new jouissance, it confounds it. It affirms itself capable of making the subject forget its misfortune. It does this better than alcohol, a wide spectrum antidepressant and anxiolytic, which Freud recognised as providing oblivion through access to an immediate jouissance that delivers one from the world.
Beyond the extension of the communicational model, hormones, in the proper sense, interest us above all for the inhibition produced by contraceptives. This will enable the relation of the subject to the “feeling of life” to be isolated as such. By separating procreation and sexual act, contraceptives played the role of spectral analysers of the desire for a child. They isolated it as such, separated from all other willing. Assisted procreation has, at one remove, separated the getting of a child and sexual desire. It is possible to get a child in a mechanical, technical fashion, whatever the desire in play. This was formerly the case, but the dimensions of desire, demand, requirements [exigence] and need were mixed with the contingency of procreation. It is medication that has brought about a veritable diffraction of these different dimensions. It thereby brings to light new pathologies that, without it, would not have appeared. A genuine subject-effect is thus produced.
Medications for the direct stimulation of erections in man (like Viagra) and their equivalent for women, which are being sought, have to be inscribed in the same register. These are not medications for the libido but analysers of the libido. Once the erection or the secretion is obtained, one has to be able to use it satisfactorily. Let us say that the medications of the libido both reveal and hide the subject’s relationship to the appetite for life.
Anaesthetics
Addressing psychiatrists in 1967, Lacan set out the position of medication in our field on the basis of another family of uses of medication. He says, “Psychiatry returns to general medicine on the grounds that general medicine itself enters entirely into pharmaceutical dynamics. Obviously new things are being produced there: one obsesses, one soothes, one interferes or modifies…” (1967). The terms “obsessing” and “soothing” situate psychotropic medication within the family of anaesthetics. In an older text, Lacan could moreover suggest that Oedipus and a dose of anaesthetic were equivalent. We could again reformulate this in the first paradigm of jouissance according to Lacan: Oedipus permits the significantisation [significantisation], the neutralisation of jouissance; in this sense, it is sublimation or anaesthesia. This is also the point that Jacques-Alain Miller chose to highlight: “Medications are forms of anaesthetic. They don’t heal, but enable us to work with determined patients” (Miller, 2000). This is true biologically, since the first neuroleptic — chlorpromazine — was developed from an anaesthetic. This discovery was produced in the great modern adventure of the extension of anaesthetics and surgical interventions: “One cannot find, in the pharmacopoeia, more heroic or more revolutionary substances: the seekers of illusion, the neuropaths, as often happens, the addicts, finally revealed the means of obtaining a sort of ‘physiological schizophrenia,’ a method for derealising the entire organism” (Dagognet 1964: p. 300).
To this epic that revolutionized surgical practice, the hypnotics must be added. Sleeping medications, by disconnecting the dreamer from the dream or the nightmare, have again brought about a subject-effect, a diffraction of need, demand, and desire.
Taken in this sense, medication articulates substance with a new dimension of demand. It is thus that, in his 1966 Lecture addressed to doctors, Lacan drew the doctors’ attention to his relation to demand, beyond his function as distributor of medication: “The scientific world pours the infinite number of what it can produce as new therapeutic agents, chemical or biological, that it puts at the disposition of the public into the doctor’s hands; and it asks him, like some distribution agent, to test them out” (Lacan 1966). Lacan reminds the doctor of his ethical place, which is to situate himself with respect to “demand” [la demande]. This ethical dimension, which necessarily accompanies medication, is not reducible to the norms of good practice. It addresses itself to the subject present in toxins, the placebo, the medication of libido, or in anaesthetics. The shadow of the subject, its desire, its jouissance, drawn tight in the vocable of demand when it addresses itself to the doctor, is indeed what is in play in medication’s relation to the body, since “a body is something that is made for enjoying, for enjoying itself” (1966: p 42).
Lacan calls the doctor back to his ethical duty with respect to the powers of medication, an apparatus that marks the irruption of medicine in science. Medication is extracted from language by science, but it is the subject who reintroduces it into the structure. The subject of medication, who accompanies it like its shadow, effects the reinscription of medication within the categories of the said. It is not a master; it is one of the master-signifiers of our civilisation. Let’s now consider medication within the categories of the said.
II. Medication captured in the categories of the said
The symbolic
The first way in which medication is articulated with the symbolic is when it is the object of demand—the demand to obtain it or the demand to be weaned off it. This is especially true of the demand for weaning. 3 It is not only Kleinian psychoanalysts who know the force of this demand.
We thus need to distinguish, within demand, the demand for an object that must bring an imaginary response and the imaginary demand for a negative symbolic object. The demand can still diverge towards requiring an exact repetition, that is, a fixation of the medication on a pure automatic repetition. The object of the demand thus moves out of its symbolic dimension. We can also separate the requirement for an imaginary object and the requirement for a real object,4 or, again, the real refusal of the object. As a paranoiac subject demanding treatment without medication said, “I am not a dangerous individual or suffering from anincurable ill; I simply suffer from my own ignorance of the rules and laws that govern our society.”
The second way in which medication is articulated to the symbolic is via the signifiers that name it. Even though it is a product of science, medication cannot do without a name. It is an integral part of the pharmaceutical industry that the invention of the name will enable the penetration of the medication and its acceptance. The medication resonates through its name. A long time ago, I had cited the case of a hysterical subject, in the full flux of anxiolytic fervour, who said he “Preferred medications ending in ‘il’ [he] to medication ending in ‘homme’ [man].” It was a question of preferring Melleril to Valium. In fact, it was a question of making man pass to his status of third person, of non-person.
The third way draws upon the fact that the remedy is inseparable from the Other as such. The old remedy was entirely contained within language. Since The Savage Mind [La pensée sauvage] (1962) and the works of Claude Lévi- Strauss, we have learnt to what point language and its tropes, metaphor and metonymy, are instruments of classification of nature and its properties. Savage thought determines the remedy.
Modern medication, too, inscribes itself in the Other, but in a different way. By elaborating knowledge, by legislating its distribution, by organizing its allocation, through the responsibility of the prescriber, medication is caught up in the finest symbolic networks of the Other. It is around medication, its powers, its imperatives, its testing, that “ethical committees” in the proper sense have been put in place, evidence of this dimension that is inseparable from the action of the substance. This is exactly what Lacan underlined in 1966 in a context where we still did not know the consequences to draw from ethics beyond deontology. It is thereby confirmed that medication, in its modern exception, “only concretely defines itself through its use” (Dagognet 1964: p. 107). There again, modern medication cannot in any way be reduced to a substance. It is inseparable from the definition of its rules of use, and, by its definition, it evokes an ethical position this definition.
The imaginary
Medication lodges itself in the imaginary by its “effects of signification.” We can first situate these by exploring what is expected of it. They are the expected effects attributed to psychotropes, whether by the subject or by the prescriber.
Ego-psychology tackles its signification effects from the direction of the ego. One contrasts medication that enables “the taking back of self control” from what is lived as a “disabling reduction.” If taking medication is lived as passive submission, it can provoke in men a profound doubt over their masculinity or even a series of concerns over their corporeal image. It is, rather, beyond the ego effects of autonomy or dependence, a matter of effects of phallic signification: medication restores phallic being or provoke an effect of castration. The imaginary is not only phallic; it is not only a matter of swelling, of the form that it retains. The imaginary can also restore itself with medication in the form of an imaginary object a, deducted from the Other so as to complement the subject.
I would inscribe, in this imaginary register, a large part of the field of what has been called “cosmetic psychiatry”, which covers all the demands to extend the field of the demand for well-being and happiness beyond strict therapeutic intervention. I spelt out the problems that it raises in my first report to the General Assembly of the World Association of Psychoanalysis in 1994,“Psychoanalysis, State, Society.”
One can make still more lists of the effects of signification: pacifying medication, spoil-sport medication, punishment medication, exclusion medication, support medication.
Perhaps it is necessary to stop at this last opposition, medication that includes or excludes the Other, to get closer to the real effects of medication. We will approach them by the effects of alienation or separation from the Other.
The real
It would be precipitate to say that the real effect of medication is the pharmacokinetic effect. This would be the real in the sense of chemistry. It is real in the sense of the “return in the real.” Let us approach it straightaway by the effect of nomination in the real. Four examples will specify this point: the first two bear on toxins, the next two on medications as such.
A psychotic subject chooses ether to drug himself with. The familial myth says that his father, a farmer, had been stripped of the heritage that was his by right. The lands of which his father had been deprived return in the ether of which one cannot deprive the son. A second subject chooses cocaine. He has few memories of his father. One is marked with happiness concerning visits to his father’s printery, where the guillotining threw up clouds of white powder. Regarding two others, these were reported to me, and bear on the psychotic subject’s coupling with medication. The first was prescribed Zyprexa. Seeing thatit is made by the laboratory Lily, the two “ailes” [the two wings but also the two “l”s of Lily] immediately make him associate Lily with “butterfly.” He sees there the sign that his virility will be harmed. He refuses. For another, persecuted by the intrusive calls of a father, himself psychotic, he requires, when “this goes bad,” to take Haldol. This, he says with irony, is “Allo père idole” [“Hallo father idol”].
The effect of nomination in the real is beyond imaginary significations. There is a system of signs, a fundamental language. “This system of signs evokes a system of denomination, cobbled together by the subject himself, from the discontinuous series of products offered by science. These products permit him to orient himself in his relations to the Other and to jouissance, in what his body incarnates or rejects.”
The real effect of medication is an effect that is outside sense. It is also what is obtained by the drug, which frees man from his “marriage” 5 with phallic jouissance. There is also a passage outside sense, a forcing of the barrier posed by this jouissance.
Through medication the subject carves up his organism differently. He carves it up by this instrument of specific knowledge that is medication. Whereas the signifier trims the body in its own way, the knowledge contained in medication trims it differently. It makes known to the subject a “jouissance of himself that is unknown,” absolutely unknown. It is only accessible through this artefact. Before the neuroleptics and antidepressants were perfected, one didn’t know how to enjoy serotonin or dopamine. More precisely, we learn to enjoy zones, parts of the body that were concealed from us. Not only do we enjoy the increase or rarefaction of neurotransmitters, but we can learn to enjoy very different receptors. The receptors D2 or D4, involved in the new medications indicated for schizophrenia, are new fields of experience that offer themselves to the subject.
Medication immediately overflows the therapeutic indication that a diagnostic confers on it. Product of knowledge, it is a machine, an instrument for the exploration of the body.
Through medication, the subject is led to be able to enjoy new parts of the body. The manipulation of doses by each subject, self-medication with the help of another, in which the prescriptive negotiation consists, produces a normedjouissance proper to each person. It is a practice of the auto-erotic norm. The belief of each subject in its symptom is actualized there in a crucial way.
Psychotropic and clinical medication
The effect of this medication on the structure of clinical evolution is difficult to assess. Lacan said in 1967, “One does not know at all what one modifies nor, moreover, where these modifications are going.” This remark still remains clinically pertinent. One can certainly reply that at the level of neurotransmitters we know better which systems are activated or inhibited. One can therefore plead for the use of new molecules, better tested in their pharmacokinetics, to the detriment of the old. The question remains regarding the clinical bond of the evolution of delusions with the use of medication.
We need to distinguish the evolution of the subject based on analytic discourse from the one that is not. If one takes the orientation given by Jacques-Alain Miller – medication enables one to work with determined subjects – as one’s point of departure (Miller, 2000), it is necessary to note that not all the subjects who address themselves to psychoanalysts are decided. Some are. The proper signifying invention that operates for them is to be established in each case. The taking of medication appears as a momentary episode in the course of a long elaboration.
When one describes the evolution of the relation of delusional phenomena outside analysis by means of the simple clinical interview and the taking of medication, the clinical lessons are disappointing. The evolution of psychotic phenomena “in the long term,” as the specialists happily put it, are not established without disagreement.
For some, the whole clinic is muddled, disorganised, and one has trouble locating the beautiful taxonomy of yesteryear, with its species and its genera. Preservation of the bond with the semblable, rapid rehabilitation, obscures what isolation in asylums had contemplated in its purity. The therapist’s position can therefore be nostalgic, or even, in resolutely embracing his times, he can consider that the only approach still possible is to make do with the ephemeral taxonomy of DSM, and describe syndromes the traces of which one can scarcely pursue beyond six months or a year.
Others, perhaps more perspicacious, consider that obsession is effective, but that it does not alter the development of forms that the classic clinical approach has isolated. They remain present among us, hidden, subterranean, appearing with “relapses” of the subject on the occasion of the cessation of treatment, of a life event or a bad encounter, programmed or not into one’s destiny. The subject and the Other pursue their conversation in the forms that modernity authorises, structured in the vein of the structure.
I will stop here, on the threshold of what would be the object of an autonomous inquiry. It would bear, not on medication, but on the evolution of clinical experience such as psychoanalysis can define it. When Lacan stated in 1967 that there had been no new clinical inventions since the time of his thesis, this was not to situate himself in the valiant troupe of “the last of the inventors,” just like the “last of the Mohicans.” He was stating that, at that time, the psychiatric clinic had been profoundly subverted by both the psychoanalytic clinic and science. Clinical history is no longer unifiable from that moment. It became the history of the dispersion of clinical systems, of their disappearance, of their juxtaposition, in a word, of their stratification. From this perspective, one would need to make an appraisal of the clinic of the “end of the clinic.”
The practice of medication, a contingent practice
Beyond the opposition between medication that encourages speech and medication that silences, let us recognise, in the medication that re-alienates the subject in the place of the Other, an essential element of the operation of “l’apparole” for the psychotic subject. It is in this operation that it could come to inscribe signs that could then be read.
Psychoanalysis is not opposed to the prescription of medication; it could make the contingent power of medication an auxiliary of l’apparole. In this operation, the psychoanalyst is a partner who has an opportunity to respond. He could do without medication on condition that he uses it properly. The Taoist aphorism tells us that when one points to the moon with one’s finger, the simpleton looks at the finger. Medication is one of the master- signifiers of our civilisation. It is the index of a mode of jouissance. It is up to the psychoanalyst to use it to designate the moon of our discourse, the bar in the big O, and to do it in such a way that the subject does not hypnotise himself with this index.
Translated by Justin Clemens
References
Dagognet, F. (1964). La raison et ses remèdes. Paris: PUF. Lacan, J. (1966). Psychanalyse et medicine. Unpublished lecture.
Lacan, J. (1967). Conférence sur la psychanalyse et la formation du psychiatre. Unpublished lecture.
Lévi-Strauss, C. (1962). La pensée sauvage. Paris: Plon.
Miller, J.-A. and Gilio, M.-E. (2000) “Interview de J.-A. Miller par M.-E. Gilio,” in Rapport sur le médicament, p. 51.
1 Laurent here quotes from Louis Robin’s translation of Phaedrus, in Platon, Oeuvres, tome 2, Paris, La Pleiade, p. 75; I have translated Plato directly from Laurent’s French. A more fulsome translation, from B. Johnson’s translation of Derrida’s Dissemination (Chicago: Uni of Chicago Press, 1981) — the text of Derrida’s which Laurent is invoking — runs “…will produce forgetfulness in the souls of those who have learned it because they will not need to exercise their memories, being able to rely on what is written, using the stimulus of external marks that are alien to themselves rather than, from within, their own unaided powers to call things to mind. So it’s not a remedy for memory, but for reminding, that you have discovered” (274e-275b).
2 “Interview de J.-A. Miller par M.-E. Gilio,” in Rapport sur le médicament, p. 51.
3 Cf. Rapport, p. 15 (“Pilule et désir d’enfant”), and p. 21 for a psychotic subject fixed by medication to a persecuting cause of all its troubles.
4 Cf. Rapport, p. 16.
5 Cf. the intervention of Lacan during the closing session of the “Journée des cartels” of the EFP in 1975