Clinical Conflict II: Training Sickness
Disease in analytic formation
While being interviewed for admission at the psychoanalytic institute where I am now a candidate, I am asked what I fear most about the process of formation as a psychoanalyst. I answer that I fear what it could do to my body—that formation not only consists of the psychic or vocational becoming of an analyst, but also is a transmission of knowledge or experience that has somatic stakes. As someone already working as a clinician, I explain that I don’t worry about the somatized countertransferential responses to patients—these are session- or case-specific bodily phenomena typical of most treatments. I spontaneously emphasize, perhaps not without risk, that as someone with a chronic illness, I am instead anxious that I could be overwhelmed by the relentless influx of drive excitation experienced in the process of analytic formation.
The drives are a border concept, circuiting between psyche and soma—depending on the quality and quantity of excitation, there are a variety of implications for how the drives operate in the subject. The analytic candidate, like anyone else, is subject to the vicissitudes of the drives, but most people don’t publicly talk about the personal or clinical implications of this, outside of the framework of countertransference or in the enclosed space of a personal analysis. Stressors or excitations of psychoanalytic training include the sheer volume of underpaid or unpaid intensive clinical work, financial stress from costs associated with formation, significant libidinal and temporal investment in the institute and its politics, and, in my case, the end of an eight-year analysis followed by the beginning of a new one.
I go on to speak about some recent experiences in the clinic that give ground to this fear. I tell the analyst about having nine sessions that very day, with my longest consecutive break being fifteen minutes. I share that in the session just prior to my interview, I was working with an endearing but floundering postgraduate whom I treat twice a week. I generally feel calm with this patient, but in that session I endured a raging headache, felt dizzy, and found myself having difficulty swallowing, as if a ball of thread was lodged in my throat. This state renders all preconscious associations inaccessible on my part, even though the patient was speaking about something very important and moving: the experience of suddenly having to put down his dog and seeing the fear in his pet’s eyes as it died. These bodily sensations feel as if they’re coursing through me and completely overwhelm my ability to think or feel present in the room with this patient and his loss.
What I don’t share with my interviewer is that lately this has been happening with increasing frequency in and outside of the clinic. I continue my narration to her: after the session I splash water on my face with shaky hands, feel immense guilt, wonder how I can withstand these disturbing somatic afflictions alongside the added elements constitutive of psychoanalytic formation, and take the train downtown for the interview. And here we are, I sardonically joke to close the story. The psychoanalyst interviewing me, a luminary in the field, appears to understand and appreciate my honesty. We mull over the countertransferential dynamics at play in the case, but I insist that it feels like something more is going on, and that this more, this excess, is the thing I fear. I refrain from mentioning, however, that it is beginning to dawn on me that I might indeed be in the middle of a relapse of the aforementioned chronic illness: Post-Treatment Lyme Disease.[1] Until I answered the interview question about my fears regarding training, I had largely repressed this possibility. A cascade of physical symptoms and attendant anxiety flood the rest of that summer.
I share the scene of the interview not only because it sheds some light on the intimacies and intensities inherent to analytic training, but also because it frames how we might begin to think of the economic import of analytic labor and formation. The polysemy of the word “economic” is in the background of everything I am discussing, but I specifically want to consider Freud’s economic theory of the drives not only because I believe it can elucidate the psychosomatic stakes of analytic formation, but also because it might be helpful for thinking through what happens in the clinic, workplace, broader culture, or community when people are experiencing certain manifestations of physical illness.
Freud’s theory of the drives is the bedrock of my institute’s approach to psychoanalysis and psychosomatics, with this latter category largely being shaped by the work of the Paris Psychosomatic School. For the Paris Psychosomatic School, the word “psychosomatic” means something different than the colloquial understanding of it as an illness caused entirely by emotional disturbance. From my understanding, they are referring to somatic complaints that appear when drive energy (libido or the death drive) is not bound psychosexually through mentalized symptoms or defenses, as is the case in neurosis, psychosis, phobia, and perversion. The overwhelming quantity of drive excitation instead finds expression through the body in the form of somatization and cannot be represented affectively or through pure anxiety—this is psychosomatics.
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Many months have passed since the interview and my physical symptoms have only worsened. I am fully relapsing with Lyme, have been diagnosed with another co-infection via bloodwork, and am being treated with an intensive (and expensive) regimen of herbal supplements and antibiotics, which produces brutal side effects. I feel completely awful without knowing why now, suffering from a litany of hallmark Lyme symptoms: migraines, acute fatigue, arthritis, neuropathy, dizziness, tinnitus, migrating pain, blurry vision, heart palpitations, a stiff neck, swollen lymph nodes, as well as difficulty swallowing, speaking, and concentrating. My patients don’t seem to notice I am ill, and I somehow don’t miss any work, despite experiencing many episodes of panic accompanying the illness, which often occur silently in session. Such episodes seem to not discriminate among my patients, and it makes no sense when I try to think of such experiences in terms of countertransference or the patient’s clinical presentation.
It is October and I have been in Lyme treatment since August. Analytic training began in September, and I am having serious doubts about my abilities to work or function at all. I anxiously fantasize about having to move back to my parents’ home across the country to convalesce, abandoning the field of psychoanalysis and my whole life in New York. In one seminar on hysteria, I feel as if I am about to collapse and panic that nobody around me is an actual doctor. The irony of the situation isn’t lost on me, and I laugh to myself while crying in the institute’s bathroom.
I attend a psychosomatics seminar led by members of the IPSO, the Institut de Psychosomatique Pierre Marty, a training institute with several clinics that serves as the locus of the Paris Psychosomatic School. This school of thought originated in the 1950s, beginning with the work of French psychoanalyst Pierre Marty, along with Michel Fain, Michel de M’Uzan, and Christian David. Prominent contemporary affiliates of the psychosomatic school include Marilia Aisenstein, Claude Smadja, and Panos Aloupis. Their theories and practice encourage a return to Freud’s first topography, which is constituted by the conscious, preconscious, and unconscious registers of the mind, privileging the economic model of the drives that Freud begins to elucidate in The Project for a Scientific Psychology (1895). The economic model considers the drive (mental energy or libido) as a product of excitation from external stimuli that can be understood in terms of two axes: quantity and quality. The quantity of excitation is somewhat self-explanatory; it refers to the amount of excitation circulating through the soma. The question of quality introduces the dynamic between pleasure and unpleasure, the discharge of tension or excitation, and how the flow of such excitation might be represented psychically, or mentalized, to use the parlance of the Paris Psychosomatic School.
Problems arise when the quantity of excitation cannot be transformed qualitatively, when drive energy is unbound (not cathected psychically) and there’s an overly abundant quantity of excitation that results in somatizations or bodily symptoms with varying degrees of severity. Why does this happen? Pierre Marty argues that there are not psychosomatic illnesses, but rather, psychosomatic subjects. A psychosomatic psychic structure can stem from early instances of trauma in which overwhelming quantities of drive excitation cannot be transformed psychically, from failures in caregiving function or object relations, and/or from a lack of development in a subject’s neurotic defenses and primary narcissism. The Paris Psychosomatic School describes patients who display a predominance of the death instinct, in which psychic tension trends towards zero, with excitation generally being bound in somatic ailments—these patients are referred to as having “poor mental functioning.” Many psychosomatic patients reportedly appear to be disaffected, speak matter-of-factly about their somatizations, and display an incapacity to dream or fantasize; this is referred to as operational thinking.
A spectrum or hierarchy of the causes and manifestations of somatizations is implied. According to the IPSO, whereas some neurotic patients can regress in a moment of low psychic functioning and experience minor or reversible somatizations, structurally psychosomatic patients have lasting disturbances in their ability to mentalize excitation. In the IPSO analysts’ clinical practice, these are the patients who tend to suffer from progressive illnesses, such as autoimmune conditions and certain cancers. Some research suggests that these patients have a greater risk of dying from their illnesses compared to differently structured individuals suffering from the same ailment. There is debate over the possibility of structural changes for psychosomatics through the IPSO’s specific approach to psychoanalysis, but the work is described as very slow, due in part to the tendency of a lack of transference from these patients. When hearing the IPSO analysts’ lectures, I pick up on simultaneous dogged determination and fatalism in their clinical material, though in my experience they always speak of their patients with profound respect. In other words, there is a sense that such patients are in a lot of trouble but that any opening in their cases will be listened for carefully and seized upon if the opportunity presents itself, because it is often a matter of life or death. Despite the clinical stakes of their work, it is at times difficult to focus: the lectures are conducted virtually and adhere to French academic traditions in that the speakers tend to give papers without many interruptions or much dialogic exchange among students. These conditions leave a lot of op - portunity for me to dissociate while becoming increasingly ill as the term wears on, wondering where I rest on the psychosomatic spectrum, and feeling completely ruined either way.
*
The work of the Paris Psychosomatic School demarcates psychosomatic from conversion and hypochondriacal symptoms, which leave me with questions about my own Lyme relapse. For hysterics, conversion symptoms arise from the repression of psychosexual conflict and libido. In other words, behind the symptom to which the patient appears indifferent, there is repressed meaning (recall, for example, Dora’s nervous cough). For hypochondriacs, on the other hand, there is also no organic illness; libido is cathected into the address to the other in their narration of symptoms, which is charged with affect. For psychosomatic subjects, there isn’t a symbolic dimension to the organic symptom; this lack of symbolization also shows up in the patient’s disaffection and absence of representational capacities. My own case puzzles me: I am extremely anxious, but my symptoms are diagnosed as organic, assuring me that I’m not completely hypochondriacal. My symptoms, taken at face value, don’t seem to have the flavor of conversion in that, from what I can tell, they don’t individually have symbolic dimensions. My illness is indeed progressive and resisting treatment, though I don’t have the structure of a psychosomatic patient. I am by all means a neurotic who is full of fantasies and has a very lively transference to my analyst, despite the sense that my dreams are dying in real time, and I can only think about Lyme disease in the rote manner of operational thinking described above.
So maybe, I think, I am a combination case, but why is this relapse happening now and what can I psychically address to get better? I feel maddened in seminar or supervision settings as I try to think about these concerns and distinctions with fellow clinicians, other candidates, and faculty at the institute. Most people look at me blankly, vaguely seem to pity me, or ignore my comments or questions about the analyst’s somatic field and my experiences working clinically while being ill. I recall a saying from a former professor, that there’s no such thing as a well person treating a sick person. I wonder about why psychoanalysis, even the drive theory I so deeply appreciate, can’t reckon with the possibility of an analyst’s physical illness or how analysts themselves are at risk of occasional drive overwhelm, too. I think about Freud’s economic model of the drives and consider other meanings of the word “economic.” I live within a privatized healthcare system that woefully under-researches my illness and fails to cover many of its treatment or more robust testing methods. I work at a very enriching but growing clinic that, for various reasons, doesn’t pay very well or offer paid time off, which is an industry standard. I must work an ethically questionable amount of clinical hours to pay for my analysis, supervision for my control case, institute tuition, student loans, healthcare, and living in New York City. The political economy of everything at play depresses me and I am exhausted, despite my passions for the project of psychoanalysis and my work.
I tell my analyst of eight years, E., that I am anxious I’m one of these doomed psychosomatic cases rather than your garden-variety hysteric like I had long thought. She asks me what I mean by that, and I tell her about psychosomatic patients’ lack of symbolization in their symptoms and spend some time trying to understand the symbolic dimensions of Lyme disease. Lyme is an illness riddled with loaded signifiers: it has a nebulous symptomatology that can present drastically differently across cases. It (hysterically) mimics other illnesses and autoimmune conditions, such as multiple sclerosis, and its bacterial structure is identical to syphilis. Lyme is also a climate-related epidemic as warming has cut down the annual dormancy period of deer ticks and expanded their geographic reach. It is difficult to accurately test for and extremely challenging to treat if it isn’t detected and attended to very quickly, which is what happened in my case—I don’t know when I got it or where. Many vocal contributors to Lyme disease forums, understandably very desperate or disturbed, occasionally advocate treatments that appear risky or unregulated, like injecting copious amounts of colloidal silver, drinking turpentine, stopping antibiotics, refusing psychiatric medications, taking ivermectin, or flatly ignoring medical doctors. I feel alienated and unsure of what to do. E. suggests that I don’t look at Lyme Reddit, which is a good idea. Though there are valences of my psyche that could, with some lifting, be read as mapping onto Lyme and its signifiers, I don’t recognize my Lyme as a symbolic expression of my un-mentalized drive energy, because it came from a tick.
I begin to spend more of my analysis thinking about the potentially symbolic nature of the timing or rhythm of the relapse, which arrived following several years of remission after initially being diagnosed and supposedly successfully treated in early 2019. I think back to when I initially got sick and how I was convinced that I was dying before I was diagnosed, after a long and initially inconclusive medical journey. I still believe that my analyst may have saved my life, not only because she was, miraculously and tellingly, the first person to suggest that I might have Lyme (for which I am forever grateful) but also because I was psychically and physically disintegrating, and she was there to receive that suffering. Despite having worked together for many years at the point of onset, the Lyme made the analysis possible and new; it created a demand in the treatment that dovetailed with so many of my more neurotic symptoms. My transference to E. was and remains one of love and indebtedness and our treatment engendered radical transformation, but during the pandemic, while I was doing much better Lyme-wise, she moved away and our work became virtual. When I decided to undertake analytic formation, I considered seeing someone in person, perhaps with a different clinical orientation. By the time of the aforementioned interview, I was more or less sure that I wanted to terminate with this beloved analyst in order to begin my training analysis with someone new. This extremely difficult decision that I had to make was discussed in the interview, too.
Towards the end of summer, E. and I decide to terminate come December. In the fall, I begin consultations with potential new analysts, which is a thrilling, terrifying, and emotionally arduous process. In the first of these consultations, I find myself sobbing the moment I begin to talk about the termination and how scared I am to start a new treatment while being so sick, yet maintaining that I must. Just prior to the second consultation with the analyst I ultimately decided to work with, I nearly pass out from dizziness and exhaustion. In the weeks that follow, despite my commitment to working with him, I completely drop out of contact. Days after our consultation, I visit the emergency room due to unending heart palpitations and chest pain. My symptoms are the worst they have ever been. This timing coincides with when I am beginning to learn about the theory of the Paris Psychosomatic School.
“Every analysis needs to confront hypochondriacal concerns by its end, to face the libidinal tension of the body in pieces.”
In November, a fellow candidate makes a brief remark about the helplessness experienced at the end of an analysis, referencing Lacan. Though E. and I had previously explored the possible link between the end of the analysis and my relapse, something about the word helplessness engenders a revelation for me. I think of the feeling of dying I had experienced when I first became ill, and that there was someone there, my analyst, who finally seemed to stop the sensation that I was falling forever. Long before I contracted Lyme, I would often say in our sessions, in varying emotional registers, I can’t hold on! It was my holophrastic signifier, gesturing towards old wounds, toward an unshakeable sense that I had been dropped and that nobody could or would pick me up. E. had been there with me, watching my life unfold, for eight formative years. She watched me grow up, and now I was preparing to leave her as a part of my path forward in becoming an analyst in my own right. My colleague’s comment jolts me into reckoning with the absolute helplessness I had subconsciously been feeling since conceiving of leaving E.
I look into the Lacan my colleague referenced from Seminar VII: The Ethics of Psychoanalysis. I find it moving and astonishing:
“. . . the function of desire must remain in a fundamental relationship to death. The question I ask is this: shouldn’t the true termination of an analysis—and by that I mean the kind that prepares you to become an analyst—in the end confront the one who undergoes it with the reality of the human condition? It is precisely this, that in connection with anguish, Freud designated as the level at which its signal is produced, namely, Hilflosigkeit or distress, the state in which man is in that relationship to himself which is his own death . . . and can expect help from no one. At the end of a training analysis the subject should reach and should know the domain and the level of the experience of absolute disarray.”
Hilflosigkeit translates not only to distress, but also to helplessness. As I prepared to leave E., at every step of our goodbye, from choosing to apply for candidacy, to selecting a new analyst, I encountered my own helplessness— my own relationship to death—in somatized form through the return of my illness.
The Lyme stared me down as if to say, can you survive this onslaught? Can you claim this choice, and your drives behind it? Commenting on Seminar 7, Anne Dunand writes:
“We can see how the end of analysis, in order to fit in with the distinction between the real and reality, must be an end without identification: the unconscious can be interminably interpreted, for it is words, words, words. The drive, on the other hand, has to be experienced as an encounter with the real; but in analysis this encounter cannot be just a reminder that a drive exists.”
The Lyme’s (re)appearance at the end of my analysis serves as an encounter with the real—with the drive as it expresses itself at this time in my life—that clarifies my confusion and vexation surrounding the theories of the Paris Psychosomatic School. Regardless of how the drives operate in a given psychic structure, to varying degrees of risk, every subject is helpless in the face of overwhelming drive energy. The real of the drives cannot—at the end of an analysis or at certain junctures in a person’s history—be mentalized, because this real is both life and death.
At the time of writing, several months into the new analysis and almost a year into analytic formation, I am much less sick. I still experience waves of symptoms from time to time, but I don’t feel like I am dying, and I don’t know why that is. I am still curious about my body’s vicissitudes but am much less anxious about the comings and goings of bodily sensations. I don’t rule out the return of Lyme symptoms, but if this happens, I think I could engage with their rhythm and how that might relate to my desire or past psychic wounds. I also think I could face that they are simply there, and fold them into my way of being an analyst, especially with patients experiencing somatic illness. In a recent seminar, citing Lacan’s “Reflections on the Ego,” the analyst who interviewed me teaches that every analysis needs to confront hypochondriacal concerns by its end, to face the libidinal tension of the body in pieces. I drift into reverie, far from my mechanical dissociation in seminars of the recent past, fancying every analytic formation as a death and rebirth in its own right. I imagine myself lying in a boat with my name carved into it, floating down a river with my hair fanning out around me, listening intently.
[1] 1. Post-Treatment Lyme Disease Syndrome is the term used for when patients continue to suffer symptoms of their illness following extended periods of treatment with antibiotics, the standard protocol for Lyme and other tick-borne coinfections.