– fortbildung –schwerpunkt Aggressivität, Agitiertheit, Weglaufdrang Wenn Verhaltensprobleme die Betreuung von Demenzpatienten erschweren Prof. Dr. med. Doris Bredthauer forderndes Verhalten (syn: Verhaltensstörungen, psychiatrische Begleitsympligten einen hohen Stressfaktor. Die Verhaltensauffälligkeiten sind der häufigste Grund für eine Heimeinweisung. Doch Alter
History essayWhat is the nature of the relationship between Analyst and Analysand The relationship between analyst and analysand in Freudian psychotherapy has many layers, depending upon the perspective from which it is viewed. On the surface it resembles the relationship between patient and medical doctor, and yet unlike a physical ailment this interaction is created by and functions in dependence upon a number of social and ideological factors. These include the techniques and beliefs about the psyche which form Freudʼs method; the historical and cultural situation in which he developed it; the background of the analysand and the role he or she assumes within the psychotherapy; the position created by the institution of psychoanalysis for the Freudian analyst; and the ostensible purpose and efficacy of the treatment. These produce the overt nature of the analyst analysand relationship, but in fact the existence of the relationship in that context gives another, cultural metaphorical meaning to the interaction. The performance of the relationship medicalises certain behaviours, emotions, and desires, and changes the understanding of moral agency. This function informs the significance of the relationship and therefore its nature from the point of view of society and its Psychoanalysisʼ influence has been far reaching, but the context of its development remains an important influence on both its theory and practice. Freud was born into the fringes of a bourgeois society still adjusting to the death of god, living in Newtonʼs clockwork universe with Darwinʼs apes as progenitors. Yet despite Kant and Bentham it was the Church which held sway over conduct, guilt, and fear. It was a rigid, patriarchal society which still believed in the duality of sinful material body and transcendent intellect. Women were seen as weak and inconstant, mentally and emotionally; a possession, a burden, and a workforce for their husbands and familie The middle class was the embodiment and upholder, as a moral duty, of a repressive social order, especially in regard of sexualityThe idiots, maniacs, and lunatics who had been cared for or brutalised within their communities 1 M. Rapport, Nineteenth Century Europe, (London, 2005), p. 251 2 J. Carroll, Puritan, Paranoid, Remissive: A Sociology of Modern Culture, (London, 1977), pp. 8-10 3 R. Fuchs, V. Thompson, Women in Nineteenth Century Europe, (London, 2005), pp. 111-113 in the eighteenth century, were now chained in asylums alongside the criminals and alcoholics consigned there by the alienistsand the courtThe wealthy retreated to chic spas or society doctors for a cure of “nerveThey avoided the word “madness” because this affliction of the poor was associated with degeneration, in other words ʻmorbid heredity or else with hygiene, which was code for sins such as masturbation, homosexuality, alcoholism, and syphilis.Freud, a brilliant humanist with a medical scientific background, lacked the worst of his cultureʼs misogyny,and yet he was not without its perspectives and prejudices.He was, however, refreshingly free of the obsession with race and sin which dominated the His “talking cure,” embodied an ideology which was at once groundbreaking and an evolution of the ideas of Charcot, Pappenheim and Breuer. The Freudian analyst discovers past traumatic events which have disrupted proper development of the analysandʼs psyche, and helps the subject to re-experience these events in a safe way. Freudʼs view is of an individual who is ʻsocially constructed albeit on a biological basisʼ.The psyche contains a tension between desire, based on sex, and repression, originating in the social constraints internalised and enforced by the reasoning mind. Desire is seen as childish and secretive and unstable; control the mark of the adult intellectHis method tames the hysterical, neurotic, obsessive, and irrational by means of reason and analysis of its hidden signs. The analyst aids 5 J. Harsin, ʻGender, Class and Madness in Nineteenth Century Franceʼ, French Historical Studies, 17, 4, (1992), p. 1050 6 E. Shorter, A History of Psychiatry: From the Era of the Asylum to the Age of Prozac, (New York 1997) p. 3, p. 17 9 T. Szasz, The Manufacture of Madness, (New York, 1970) p. 184.
10 E. Shorter, op. cit., pp. 29-31 11 S. Freud, ʻSome psychical consequences of the anatomical distinction between the sexesʼ, in J. Strachey (ed) The Standard Edition of the Complete Psychological Works of Sigmund Freud, vol. XIX, (London, 1974) “I cannot evade the notion … that for women the level of what is ethically normal is different from what it is in men.” 12 J. Mitchell, Psychoanalysis and Feminism, (Ringwood, 1975), p. 322 13 B. Friedan, ʻThe Freudian Mystiqueʼ in J Mitchell Psychoanalysis and Feminism (Ringwood, 1975) pp. 93-94, p. 324.
14 M. Borch-Jacobsen, ʻHypnosis in Psychoanalysisʼ, Representations, 27, (1989) p. 97 15 E. Wilson, ʻPsychoanalysis: Psychic Law and Order?ʼ Feminist Review, 8 (1981), pp 63-65 16 S. Freud, Introductory Lectures on Psycho-Analysis, (London, 1929), pp 297-298 and takes the part of what Freud called the super-ego, while the patient reveals the motivations of their unconscious id by word association, dreams, and slips of the tongue. The analysand submits to a process which involves leaving aside his or her reasoning intelligence while reporting dreams and feelings, and accepting the interpretation of subjective psychic processes which is offered by the analyst. The analyst, meanwhile, puts aside all emotion and acts as a disembodied intelligence, floating behind and above the analysandʼs prone figure Pinel had briefly seen humanity in the freak show of the mad poor, predominately female, locked in the asylums of France. At Bicêtre Hospital in 1793, and later at the Saltpêtière, he replaced bleeding, purging, and blistering with observation, conversation and an attempt to understand the psychological cause of the patientʼs symptoms. His approach was soon lost in overcrowding and brutal incarceration, but Freud returned to and improved Pinelʼs method, creating a rationale and making of it what Freud insisted that analysts charged professional fees; he also considered the neuroses of the lower classes to be intractableThus the analysand was necessarily middle class, afflicted by forces outside their control and yet seemingly internal. Although initially resisted by alienists and institutional psychiatrists, Freudʼs ideas quickly became widespread in the first decades of the twentieth century. His emphasis on the sexual underpinnings of identity led to a popular fascination with his theories and also to their lack of favour with scientific establishment. There was a widespread belief, at least in the United States and in Europe outside of Spain and Italy, that society was changing especially in attitudes to seIt was said that the unhappy, not just the mad, flocked to the new treatment As Szasz points out, however, mental patients are created by the ascription of certain behaviour, characterised as deviance, to a thing called mental illness. With the widespread popularity of at least a simplified version of Freudʼs ideology throughout Western 17 E. Engelman photographs of consulting rooms, Bergasse 19, Vienna, Sigmund Freud Museum, Vienna URL: accessed 2 May 2008.
20 S. Freud, Therapy and Technique, (New York 1963), p 145 22 J. Burnham, ʻThe Reception of Psychoanalysis in Western Cultures: An Afterword on its Comparative Historyʼ, Comparative Studies in Society and History, 24, 4 (1982), p. 605 bourgeois society, large numbers of people turned up for treatment of what they or those close to them now thought of as a medical condition. If the patient and the society are to have confidence that this social and moral failing is a disease, susceptible to a cure, then the analyst must have the trappings of medical and scientific authority. Much of Freudʼs work was an attempt to legitimate his new theory and technique. He did so, not by following Boyle, who had given detailed instructions for the reproduction of his experiment but by the creation of an psycho-analytic priesthood whose lengthy initiation gave access to hermetic knowledge. Thus justified, the analyst assumes the role of both exorcist and confidant. The analysand wants a release from suffering whereas the analyst wants him or her to once again function within the expectations of society This is what the analyst and analysand bring to their interaction, how society conceives of them and how they conceive of one another. But it is the function of the interaction, from various points of view, that is the key to its nature. Ostensibly, it is the same as the interaction between a doctor and a patient with physical illness. A person suffering problems in living consults the psycho-analyst. A pathology is diagnosed and a course of treatment entered into. Several things about this apparently straightforward purpose are rather interesting. The first is that unhappiness and inability to function within social expectation can be considered a problem with a medical or scientific solution. The second is that this remains the case although Freud had limited success in the six cases he documented, and psycho-analysis has not done any better since then. There has been an ongoing debate about whether proper statistical analysis of the success of Freudʼs treatment is possible, and whether the results of psycho-analysis provide evidence that his theories about the psyche are correct.It has been conclusively shown, however that patients undergoing psychoanalytic treatment have absolutely no better chance of recovery than those who have no treatment: psychoanalysis does not wo That the technique is ineffective has not been known for half of the history of the discipline, and even now is neither accepted nor disseminated by practitioners. 25 F. Salloway, ʻReassessing Freudʼs Case Histories: The Social Construction of Psychoanalysisʼ, Isis, 82, 2, (1991) p. 262 26 Another paradox: his heavily elided case notes are not all of successful treatments. He means the reader to believe that he is not presenting an image, and yet this is precisely what he does. op. cit., p. 261 27 E. Kurtzweil Freudians and Feminists, (Boulder, 1995), p38 ʻpsychoanalytic therapy aims at curing the individual so he can continue to function as part of a sick civilizationʼ 28 A Grunbaum, ʻEmpirical Evaluations of Theoretical Explanations of Psychotherapeutic Efficacy: A reply to John D Greenwoodʼ, Philosophy of Science, 63, 4, (1996) p. 641 29 S. Rachman, ʻThe Clinical Validation of Psychoanalytic Theoryʼ Noûs, 17, 2, (1992) p. 404 Furthermore, the equivocal anecdotal evidence is obscured by the high rate of spontaneous remission, the length of treatment, and the investment of both analysts and their patients in the success and reputation of psychoanalysis. Nevertheless, the lack of efficacy in its ostensible purpose is an indication of psycho-analysisʼ usefulness in other ways.
Here is the crux of the matter: the ʻanalytic situationas enacted in the analyst analysand relationship, has a functional meaning: the demonstration of a knowledge about humanity and society, and the creation of that knowledge by the process of this demonstration. In this it is like an exorcism or a passion play; although it happens behind closed doors, it acts as a public explanation of certain understandings about the psyche; it creates a certain truth. The Christian passion play evoked the sin and misery of corporeal existence and the redemption of submission. Exorcism made manifest the devil, the victory of the Church, and the powerlessness of man. The functional meaning of the process of psychoanalysis, and therefore the metaphorical nature of the analyst analysand relationship, is similar to these earlier performances and also to confession The basis of this is the medicalisation of many aspects of behaviour, emotion, and desire. The enactment of psychoanalysis creates from the internal and subjective a reification of previously mysterious forces in scientific and medical terms, so that they become understood, external, and objective. This process had begun with the rise of the asylums a century earlier, but where that was focused on the poor and dependent upon a ideas of race and contagion, the psychoanalytic ideology encompassed the childhood, sexual desire, and social functioning of every individual of every cla Asylums had been for the poor and proof of innate flaws of character or heredity 30 E. Erwin, ʻThe Standing of Psychoanalysisʼ, The British Journal for the Philosophy of Science, 35, 2, p.128 31 J. Derrida, Resistances of Psychoanalysis, (Stanford, 1998), p. 93 32 M. Foucault, The Will to Knowledge: History of Sexuality Volume 1, (London 1988), p. 67 33 There is no scientific evidence that Freudʼs claims about the functioning of the psyche are true, so the word “scientific” can be used in respect of his ideology only in terms of the appearance which Freud and the institution he created have carefully manufactured for the discipline, in spite of this lack of objective evidence and the defense by the psychoanalytic establishment that their claims are not in fact testable (thereby admitting that the ideology fails Popperʼs standard for “science”.) E. Erwin “The Truth about Psychoanalysis”, Journal of Philosophy, 78, 10, pp. 549-560. Also F. Sulloway, op. cit., p. 246.
34 L. Irigary, Speculum of the Other Woman, (Ithaca, 1985), p. 134 35 R. Chase, “Jules Michelet and the Nineteenth Century Concept of Insanity: A Romanticʼs Reinterpretation”, French Historical Studies, 17, 3, (1992), p. 729 but the bourgeoisie embraced oedipal complex and penis envy, the licence to talk about sex and the surrender of moral cause without invocation of guilt or blame. Thus, the analyst analysand relationship functions as a ritual demonstration of the transformation of the personal, ethical, and political character of human development, sexuality, and personal conduct into that which is technical and pathological. The analysand enters into a state of dependence on the analyst which is analogous to a childʼs dependence upon a parent. He or she gives up autonomy in return for acceptance into and of a system both practical and ideological. It is the social struggle made internal and explicit: worldly motifs of control, repression, power, secrecy, gender, and sexuality are conceived as motives and forces in the psyche. As above, so below: the external tension between morality the law and human needs and desire was recast as an internal drama between ego, super-ego, and id. Freudʼs patient “Dora” is the perfect example – she is unhappy but more importantly she is no longer able to function as her family requires. Her unbearable social situation is not comprehensible, but “madness” and Freudʼs interpretation of the processes of her psyche are, paradoxically, convincing.This how the ideology and its demonstration act as a mechanism of control. Prison and asylum enforced compliance with the industrial ageʼs labour requirements in the working classes by pain and incarceration,but the bourgeoisie although largely immune to these institutions were nevertheless seduced by the ideology and technique of psychoanalysis. Its efficacy might be questionable but it did no harm and conferred no shame. Politically, socially, and even subjectively; morality and autonomy had been replaced by recognition of impersonal mechanistic force based in development, biology, and sexuality. Discomfort, whether internally or externally caused, was recast as disfunction, and the solution was submission to a medical process in which a properly authorised technician made the necessary psychic adjustment. The analyst, says Derrida, is ʻon the side of order, on the side of a subtly authoritative violenceʼ. This violence is the reframing of rebellion as 38 J. Harsin, ʻGender, Class and Madness in Nineteenth Century Franceʼ, French Historical Studies, 17, 4, p. 1051.
39 T. Szasz, Ideology and Insanity: Essays on the Psychiatric Dehumanization of Man, (London 1973) p. 2 40 S. Freud, Case histories I : ʻDoraʼ and ʻLittle Hansʼ, ed., trans. J. Strachey, trans. A. Strachey, ed., A. Richards, (Hammondsworth, 1977) p. 66-69 41 A. Scull, ʻMadness and Segregative Control: The Rise of the Asylumʼ, Social Problems, 24, 3, (1977) p. 341 42 T. Szasz, op. cit., p 6 ʻmoral autonomy is removed from the patient and transferred tot he determinism of the situation. An illness or a condition rather than a choice. These ʻdiseasesʼ are … largely human conflicts and the products of such conflicts.ʼ 43 J. Derrida, op. cit., p. 94.
illness. To give just one example, “Doraʼs” mother contracted both gonorrhoea and syphilis from her husband, and began to clean the house compulsively. Freud, with Doraʼs help, diagnosed her motherʼs ʻpsychosisʼ without noticing that in doing so they had let Doraʼs father slip from view The analysand enters willingly into the technique and the ideology; although treated as a child-like bundle of developmental forces he or she is in a personal relationship with the analyst which centres around analysandʼs own needs. Freudʼs encountered a large number of cases of incest, but chose to understand them as fictions of the developmental forces at play in the minds of his patients rather than the social reality of cruel men in a society which awarded the head of a family absolute powerThis is his cowardice and convenience, but it is also the philosophical approach of his ideology; the analysand is the location of the disfunction, but insight and cure lies with the analyst.
Foucault identified four strategies by which sexuality was made an instrument of power relations, beginning in the eighteenth century: the hysterisation of womenʼs bodies, the pedagogisation of childrenʼs sex, the socialisation of reproductive behaviour, and the psychiatrisation of perverse pleasure. In terms of psychiatry, he sees psychoanalysis as an opposition to ʻthe political and institutional effects of the perversion-heredity-degenerescence system.However the ideology of psychoanalysis provided a pseudo-scientific justification for these very factors, and most importantly emphasised and legitimised gender differenceamong the bourgeois intellectuals of Europe and the United States. In this the psychoanalytic situation constituted a mechanism of engagement and propaganda. The analysand looks for absolution and receives instruction. Female desire, in particular, was no 45 J. Harsin, ʻSyphilis, Wives, and Physicians: Medical Ethics and the Family in Late 19th Century Franceʼ, French Historical Studies, 16, 1 (1989) p 90.
46 M. Borch-Jacobsen, D. Brick, ʻNeurotica: Freud and the Seduction Theoryʼ, October, 76, (1996), p. 43. ʻthe Oedipus complex, infantile sexuality, the wish-fantasies, all of Freud's self-proclaimed "discoveries" are arbitrary constructions designed to explain away his patient's stories of incest and perversion while simultaneously excusing the method that had provoked them.ʼ 48 L. Fishbein, ʻThe Snake Pit (1948): The Sexist Nature of Sanityʼ American Quarterly, Winter (1979), p. 660 longer solely possessed by the whorebut it in Freudʼs view to want other than heterosexual reproduction was to be locked in childhood This illustrates the symbiosis between science and ideology: our language and our preconceptions frame the questions and therefore determine the types of answer which are possible. Freud was an innovator but he was a bourgeois male of his era. Darwinʼs development of human brain from monkey becomes Freudʼs development of the adult ego and superego from the id. Progress denied is disfunction. Likewise Newtonʼs clockwork universe is seen in Freudʼs process-based psyche. What is less obvious yet more important is Freudʼs separation of reason from emotion. This is the old Christian separation of pure spirit and impure flesh, recast. The egoʼs cool intellect rules the idʼs dangerous passion, as Descartesʼ mind owns body, and as Europeʼs male patriarchs ruled, and distrusted, their women and children. Ironically this alienation of rationality from feelings, male from female and human from nature, is exactly what psychoanalysis was in many cases treating at the same time as being the very thing Freud (and the scientific method he pretended to employ) was And even as a man seeks to rise higher and higher – in his knowledge too – so the ground fractures more and more beneath his feet. “Nature” is forever dodging his project of representation, of reproduction. And his grasp. That this resistance should all too often take the form of a rivalry within the hom(m)ologous, of a death struggle between two consciousnesses, does not alter the fact that at stake somewhere, ever more insistent in its deathly hauteur, is the risk that the subject (as) self will crumble away. Also at stake therefore is the “object” and the modes of dividing the Freud interpreted hysteria and neurosis as pathology rather than communication and his technique reflects this. The analysand becomes the object rather than subject of analysis, and the analyst mesmerises himself with an ideology which 49 J. Carroll, Puritan, Paranoid, Remissive: A Sociology of Modern Culture, (London, 1977), p. 11 50 A. Rossi, ʻSex Equality: The Beginnings of Ideologyʼ, in Toward a Sociology of Women, (New York 1972) ʻFreud codified the belief that men get more pleasure than women from sex, in his theory of sexual development of the female. The transition from an early stage in which girls experience the clitoris as a leading erogenous zone of their bodies to a mature stage in which vaginal orgasm provides the woman with her major sexual pleasure. Women who did not make this transition were viewed as sexually “anaesthetic” and “psychosexually immature”.ʼ 51 L. Irigary, Speculum of the Other Woman, (Ithaca, 1985), p. 134.
52 T. Szasz, Ideology and Insanity, (London, 1973), p. 19.
separates him from the physical and social, and thus even emotional reality of his Thus analyst and analysand engage in a scenario which recapitulates the Christian separation of intellect from emotion and mind from body. In the form of psychoanalysis it reifies the subjective and hidden as deterministic objective forces, removing control, personal autonomy, and social responsibility. However this scenario takes the form of a personal and intimate relationship, albeit one-sided, which has at least the appearance of humanist compassion. This is the essence of their relationship: the analysand has the unknown quantified and his or her distress legitimated, whilst engaging in what seems a compassionate dialogue; the analyst will bear responsibility for the analysandʼs return to social functioning whilst remaining dispassionate. For society, however, the performance is part of a larger process of medicalisation with implications throughout society, which proves and demonstrates the reduction of subject to object, human to functional; the intimate commodified and simulated A passion play or a psychodrama: the analyst as thaumaturge and the analysand, no longer as confessor, but alembic.
54 J. Derrida, op. cit., p. 93.
Borch-Jacobsen, M., Brick, D. ʻNeurotica: Freud and the Seduction Theoryʼ, October, 76, (1996), pp. 15-43.
Burnham, J., ʻThe Reception of Psychoanalysis in Western Cultures: An Afterword on its Comparative Historyʼ, Comparative Studies in Society and History, Chase, R., “Jules Michelet and the Nineteenth Century Concept of Insanity: A Romanticʼs Reinterpretation”, French Historical Studies, 17, 3, (1992) pp. Carroll, J., Puritan, Paranoid, Remissive: A Sociology of Modern Culture, (London, Derrida, J., Resistances of Psychoanalysis (Stanford, 1998) Erwin, E., ʻThe Standing of Psychoanalysisʼ, The British Journal for the Philosophy Fishbein, L., ʻThe Snake Pit (1948): The Sexist Nature of Sanityʼ, American Quarterly, Winter, (1979), pp. 641-665 Foucault, M., trans. Hurley, R., The Will to Knowledge, The History of Sexuality Freud, S., ed. trans. Rieff, R., Therapy and Technique, (New York, 1963) Freud, S., trans. Riviere, J., Introductory Lectures on Psycho-Analysis, (London, Freud, S. ʻSome psychical consequences of the anatomical distinction between the sexesʼ, in J. Strachey (ed) The Standard Edition of the Complete Psychological Works of Sigmund Freud, vol. XIX, (London, 1974) Wilson, E., ʻPsychoanalysis: Psychic Law and Order?ʼ, Feminist Review, 8 (1981), Freud, S. Case histories I : ʻDoraʼ and ʻLittle Hansʼ, ed., trans. Strachey, J., trans. Strachey, A., ed., Richards, A., (Hammondsworth, 1977) Fuchs, R., Thompson, V., Women in Nineteenth Century Europe, (London, 2005) Grunbaum, A., ʻEmpirical Evaluations of Theoretical Explanations of Psychotherapeutic Efficacy: A reply to John D Greenwoodʼ, Philosophy of Harsin, J., ʻGender, Class, and Madness in Nineteenth Century Franceʼ, French Historical Studies, 17, 4, (1992) pp 1048-1070 Harsin, J., ʻSyphilis, Wives, and Physicians: Medical Ethics and the Family in Late 19th Century Franceʼ, French Historical Studies, 16, 1 (1989) pp. 72-95.
Irigary, L., Speculum of the Other Woman (Ithaca, 1985) Borch-Jacobsen, J., ʻHypnosis in Psychoanalysisʼ, Representations, 27, (1989) pp. Kurtzweil, E., Freudians and Feminists (Boulder, 1995) Mitchell, J., Psychoanalysis and Feminism (Ringwood, 1975) Rachman, S., ʻThe Clinical Validation of Psychoanalytic Theoryʼ Noûs, 17, 2, (1992) Rapport, M., Nineteenth Century Europe, (London, 2005) Salloway, F., ʻReassessing Freudʼs Case Histories: The Social Construction of Psychoanalysisʼ, Isis, 82, 2, (1991) pp. 245-275 Scull, A., ʻMadness and Segregative Control: The Rise of the Insane Asylumʼ, Social Problems, 24, 3 (1977) pp. 337-351 Shorter, E., A History of Psychiatry: From the Era of the Asylum to the Age of Szasz, T., Ideology and Insanity: Essays on the Psychiatric Dehumanization of Man, Szasz, T., The Manufacture of Madness, (New York, 1970)
FOLHETO INFORMATIVO: INFORMAÇÃO PARA O UTILIZADOR Leia atentamente este folheto antes de tomar o medicamento • Conserve este Folheto Informativo. Pode ter necessidade de o reler. • Caso tenha dúvidas, consulte o seu médico ou farmacêutico. • Este medicamento foi receitado para si. Não deve dá-lo a outras pessoas; o medicamento pode ser-lhes prejudicial, mesmo que apresentem o