Cure


I


In times of crisis we must all decide again and again whom we love.

Frank O’Hara, ‘To the Film Industry in Crisis’

There is a story told about one of Freud’s early followers, Alfred Adler, that often, when he did an initial consultation with a patient, he would ask them – after they had given him an account of their symptoms and taken a history – ‘What would you do if you were cured?’ They would answer, and he would say, ‘Well go and do it, then.’ It is a seemingly heartening story, not least because it suggests that the patient knows what he wants, and what it would be for him to be cured; and, indeed, that he may well have the wherewithal to do what he has wanted to do (being cured means finally doing something you have always wanted to do). As though a symptom is simply an inhibition; and the aim of analysis – in the Kleinian analyst Roger Money-Kyrle’s words – is ‘to show the irrelevance of the inhibition’ (or rather, to show the irrelevance of the inhibition by revealing its apparent relevance). The cure here, from a psychoanalytic point of view, is the cure of an inhibition. There is something – perhaps many things – that a person wants to do that he needs to feel he is unable to do. He suffers both from his inhibition and from his fear of his more disinhibited self; of the more or less grandiose fantasies he has about his disinhibited self.

Adler’s device can be seen now as an early example of a version of what came to be known as existentialist psychoanalysis; or psychoanalysis without the unconscious. The patient – like everyone else, according to Sartre – is the sum of their choices. And essentially what they are suffering from is their fear of freedom, their refusal of their actually existing choices. They are not, they suppose, the authors of their own lives – their symptoms are; they have delegated their agency to something they call the unconscious, when once they might have delegated it to the gods, or God, or to the powers that be. But Adler’s practice, in the context of the early, more experimental days of psychoanalysis, is instructive: it suggests that the patient knows what it would be to be cured – has their own idea about cure – and can imagine the consequences of their cure (the more contemporary, more nuanced family-therapy version of Adler’s question is ‘How would your life be different if you were cured?’).

To be cured, then, is to be leading one’s preferred life: this is one of our terms for desirable change. It is assumed, in other words, that the patient is thoroughly in the know about his own life; he knows what he really wants, and he knows what the consequences will be of this successful wanting. He is a pragmatist, and his project is to do what he can to get the life he wants; he wants to extend his repertoire of what is possible. Freud’s psychoanalysis – which is simply one more way of taking people seriously – adds to this that the patient also doesn’t know what he wants as yet, and has gone to great lengths not to know; and is anyway always conflicted around and about his wanting; that the patient also enjoys his suffering – the punishment of it, the inhibition in it; he enjoys his lack of enjoyment – and so doesn’t want to get better, or doesn’t only want to get better. And that one cannot know the consequences of one’s wanting, because one can’t know the future except as an assumed replication of the past (Freud’s word for knowing the consequences of one’s actions is ‘wishing’). Freud’s psychoanalysis, that is to say, takes the medical model of cure – at once a healing and a relieving of pain – and puts it into question (the cure of and for a broken leg is less contentious than the cure for a broken heart). Where we might think there are only conscious choices (and unconscious choices), we have, in Freud’s view, unconscious determinisms; when we know what we want, we may be taking refuge from what we more troublingly want, or from what we as yet don’t know that we want (we may underestimate our need to displace our wants, to relocate them to make them more acceptable). We are not, to mix Freud’s familiar metaphors, masters in our own houses, we are driving the horse in the direction the horse wants to go. The psychoanalyst’s concept of cure is as unconsciously determined as the patient’s – and as ideologically determined as anything else in the prevailing culture. What is acculturation if not the formulation, tacitly or otherwise, of the individual’s aims and objectives? To grow up is to learn what it is to be better.

One of the ways of describing how psychoanalysis revises (and reprises) the medical model of cure, I think – though Freud was not always either explicit about this or conscious of it – is to say that it re-presents the concept of cure as if it is, unavoidably, a question of morality, a moral issue; as though the so-called ‘good life’ of ancient and traditional philosophy has been somehow all too literally replaced, or displaced, by the criteria of health of modern medical science; the good person has been redescribed as the healthy person (without the question ‘What is health good for?’ being asked, health tending to be less controversial than goodness: health as the solvent, the redescription of morality). As though shared knowledge has replaced each individual, personal hope. As though to know what it would be to be cured would be to know more or less what a good life was, if only for oneself. As though, in a sense, medical science could cure us of the perplexities of morality (by telling us who we are, it tells us who we can be); what Foucault described in Madness and Civilization as ‘the doctor–patient couple in which all alienations are summarized, linked and loosened’.

Once the symptom is seen as a making of meaning by an organism enigmatic to itself, rather than as a malfunctioning of a potentially well-functioning system, the treatment becomes a less obviously normative project; the aims of the treatment, the concepts of cure, are there to be argued about rather than merely consented to. As we shall see, psychoanalysis – which Freud wanted to be a part of medical science – was to expose the oversimplification of the concept of cure in medicine: at least when it came to so-called mental illness. Cure being a consensus, among any given group of people, about what health is, and so about the aims and objectives of certain kinds of medical treatment; and where cure may not always be possible, it is useful as an organizing aim, a regulative target (‘How do I know if I am cured?’ becomes a question of not simply whether my suffering has been alleviated but ‘Who am I going to ask that can tell me?’ or ‘Which criteria for cure can I assent to?’). The concept of cure, in other words, is quite literally a question of criteria; of whose criteria we are meeting, and of our reasons for those particular criteria as satisfying. Where there are ideas about cure, there are shared criteria in play, however tacit or unconscious; criteria, fundamentally, about what is good, what is of value, what about ourselves and our lives should be nurtured and encouraged.

Without at least a concept of cure, or conversations about cure, medicine wouldn’t make sense; likewise psychoanalysis, Freud would discover, only made sense with and without a concept of cure. And through psychoanalysis – always only a form of local knowledge – Freud would also discover, of course, the limits of the making of sense, and the competing claims about sense-making. It wasn’t long before psychoanalysts also had to imagine what psychoanalysis would be like without agreed aims, without an agreed concept of cure, of acceptable goals of change. As though psychoanalysis may have opened something up that couldn’t be foreclosed by compelling representations like concepts of cure.

So there are versions of psychoanalysis in which the aims, however various or contradictory, can be articulated, as in medical treatment. And there is a more radical version of psychoanalysis – suggested by Freud’s writing, but not formulated as such by him – in which it would make too much of the wrong kind of sense to suggest that there could be an aim for psychoanalytic treatment, or too definitive an aim; the formulators of such aims would already have an omniscience that the theory itself disqualifies (you can’t really be an expert on the unconscious; you can only make suggestions about such a thing: you can only, that is to say, be a student of psychoanalysis). In this version of psychoanalysis, an aim for psychoanalytic treatment could only be a contradiction in terms, implying as it does that there is someone who is supposed to know the aim; or who could know the aim beforehand (the aims of a psychoanalysis could evolve through the treatment: I could, say, begin the treatment wanting my symptom to be removed, only to discover through the treatment how much I could enjoy my symptom if I put my heart into it).

If the concept of cure is not already there, fixed and formulated, then what else could it refer to? We might, for example, that we know a psychoanalytic treatment is working when the patient’s concept of cure, his sense of what it would be to be better, evolves. There are journeys in which we know where we are going, and journeys in which we do not; or do not need to. Psychoanalysis, as Freud discovered – and partly in spite of himself – was always both. There would be psychoanalysts after Freud – most notably, in Britain, Wilfred Bion and Marion Milner – who would claim that too certain a destination was itself the saboteur of psychoanalytic treatment. That wanting change – wanting specific change – could sabotage the possibility of change. That the analyst’s wish to cure could waylay the advantages that could be gained by psychoanalysis. That the taken-for-granted cure could be a lure we should be suspicious of. There can be nothing more defensive than knowing what one wants. Cure, if at all possible, is what one tends to want from a doctor. What one might want from the new kind of doctor called a psychoanalyst is less than clear. ‘Anxiety arises,’ Bion writes anxiously in Cogitations,

because one knows that analysands come with an idea of cure, and one knows it is almost certain that they will not get, and cannot get, what they call ‘cure’. Almost – but not quite. But even supposing that one can lead them to something better – a very large supposition – even that is far from certain. What then? Is it possible simply to say, ‘Try it’? Much analysis, and even more psychotherapy, is ludicrously omnipotent and optimistic.

It is almost certain that we won’t or can’t get what we want, partly because, from a psychoanalytic point of view, we are largely unconscious, unaware, of what we want, and what we want is, as Freud wrote, in excess of what any object can provide (the exorbitance of desire is his theme). But if much analysis and more psychotherapy – not to mention its theory – is ‘ludicrously omnipotent and optimistic’, it is because the analysts are, consciously or unconsciously, complicit with their patient’s omnipotence and optimism; omniscience and optimism, like omniscience and pessimism, tending, rather, to go together. We may only know that we want to change, but not how we want to change. And yet, it should be noted, Bion broaches, despite his patent misgivings, the idea of ‘something better’ than a cure; thereby inviting us to imagine what might be better than a cure, what might be a better aim for someone going into psychoanalysis. Psychoanalysis may be able to provide something better than a cure. It has certainly enabled Bion to think and write of there being something better than a cure.

So the idea, for example, still promoted by some psychoanalytic schools, that at least part of the psychoanalytic cure is the patient’s identification with, and introjection of, the analyst as a good object – a kind of guardian angel inside you that helps you with your life – would be distrusted; partly as another example of the analyst already knowing what is good for the patient, and indeed supposedly knowing how psychoanalysis works; both, of course, depending on knowing what a cure is. The psychoanalytic question here would be: what are our identifications a self-cure for? When I identify with someone – when I find myself wanting to be like someone else, or when I recognize myself in a fictional character – what am I not wanting to know about myself? Or rather, what am I not wanting to experience myself as? Cure by identification might mean assuaging anxiety by sidestepping useful doubts about oneself. It may mean a delegation of one’s own potential, a foreclosing of possibility. As though we are the animals who always want to get stuck, to fix ourselves in forms, in formulas, in preferred pictures – in representations. Psychoanalysis – and nowhere more than in its concepts of cure – is prone to be both complicit in and to counter the kidnap of representations.

A cure, then, is something we might aim for, if not always achieve. If you have a broken leg, or a fever, you know what is to be aimed for; if you have a broken heart or a sense of shame, it is not quite so clear. To understand psychoanalysis you have to see where the analogies for it do and don’t work. And how it makes you think and talk differently about getting better. Patients come to psychoanalysis with an idea of cure because, historically, they have been to medical doctors, and before that they have been to religious healers. A culture that believes in cure is living in the fallout, in the aftermath, of religious cultures of redemption. When Bion writes of ‘something better’ than cure, he is playing on the idea of cure as getting better, with all its moral implications. The fundamental question being: what is it for any individual to get better (better at what)? Where do we get our ideas about this from, and what can we do with or about them? So much depends upon the available pictures we have about what it is for us to be better than we are, to improve. This is easier to assess in, say, sport or business or medicine than in morality or art or, indeed, psychoanalysis (what is it for the psychoanalyst – or any so-called therapist – to improve, or get better?). Psychoanalysis, that is to say – and this may be both salutary and topical – allows us to have second thoughts about success and self-improvement. In his book Second Thoughts, Bion writes, apropos of psychoanalytic treatment, ‘It is necessary to be aware of “improvement” which may be denial of mystical qualities in the individual.’ Self-improvement can be self-sabotage. Too knowing; too knowing of the future. A distraction, a refuge from one’s personal vision.


II


One could almost say that the assumption of the cure position is also an illness.

D. W. Winnicott, ‘Cure’

When the British analyst Masud Khan wrote his paper on cure in psychoanalysis, he gave it a duly complicated title, alerting us to cure as a problem of knowledge – ‘Towards an Epistemology of the Process of Cure’ – and began with a necessary admission: ‘It is a well-known fact that psychoanalysts shirk using the concept of cure in their written work.’ It could have been entitled ‘Towards a Theory of the Process of Cure’. And it is responsibilities that people tend to shirk, and if they shirk using the concept of cure in their written work, we can infer that cure is something they do, perhaps, speak about among themselves. Why then are psychoanalysts so evasive, so cautious about the concept of cure? The responsibility shirked – using the concept of cure in their written work – would seem to be of the most ordinary kind: it would be a declaration of therapeutic intent, a promise of sorts, in which the analyst proposes what she has to offer that the patient might need. It would present psychoanalysis as simply another commodity in a commodity culture, and not as the anti-commodity that it is.

At its most minimal, the patient wants something they have been unable to get elsewhere – call it relief of suffering, enhanced freedom – and the analyst has a treatment that he values and wants to practise. To write of the concept of cure may involve the analyst in making controversial claims about the efficacy of his work; it may, at its worst, encourage the making of false or dubious promises; it may promote spurious success stories. And it may expose failure. But above and beyond this it raises the difficult questions that are at the heart of psychoanalysis, though not always at the heart of medicine: what has what the analyst wants for the patient got to do with the patient? And what is the significance, the history, of what the patient expects from the doctor? This patently replicates one of the essential perplexities of development: what has what the parents want for (and from) the child got to do with the child and her development? And at this point, as each psychoanalytic writer states the aims of psychoanalysis, everybody comes along with their specification: for Anna Freud and Winnicott, for example, the aim of analysis is to facilitate the patient’s development; for Klein it is for the patient to reach what she calls the depressive position; for Lacan it is to enable the patient not to betray their desire, and so on. This – as this brief menu of options and possibilities makes clear – is where the trouble starts, and where the real interest of psychoanalysis begins.

In presenting the aims of psychoanalysis, their concepts of cure, are analysts doing anything more than adding to the culture’s image-repertoire of the good life? Are they simply telling us what, in their view, people at their best can do, adding another ego ideal to the best selves on offer in the culture? There may, of course, be nothing wrong with doing this; but psychoanalysis could also be a way of wondering whether there might be anything else one could do; other than, as it were, stocking the supermarket shelves with new products, new ideals for ourselves. Ideals, one should perhaps add, that one is unlikely to be able to live up to. If psychoanalysis, with its concepts of cure, simply adds to the stock of available ambitions, it may be more of the problem than any kind of solution. It is perhaps better used to understand and experience the nature of ambition itself: to understand how hope works.

Khan’s brief and lucid paper provides what is perhaps a questionable progress myth in the psychoanalytic use of the concept of cure. He cites instances from Freud in which both Freud and Khan are clearly working out, however casually, what, if anything, the concept of cure has to do with psychoanalysis. He begins with a 1909 letter from Freud to Jung. ‘To salve my conscience,’ Freud writes, ‘I often tell myself: above all, don’t try to cure, just learn and earn some money! These are the most useful conscious aims.’ Presumably he has to tell himself this so often because as a doctor he is tempted to try to cure his patients (this is what his conscience tells him). As a cover story for this understandable desire, he suggests learning and earning his living; it is intimated that if he profits, the patients may as well. As though some kind of mutuality was the name of the game. But we should take seriously at this point the fact that learning from the patient is proposed as both an alternative to trying to cure them and a way of curing them. Clearly, if you can learn from the patient, you have broken the spell of your own disabling omniscience.

‘In spite of his adamant refusal to be caught up with any sort of therapeutic evangelism,’ comments Khan, ‘there is a definite, and progressive, theory of cure in the writings of Freud.’ ‘Progressive’ here depends on what counts as progress. We should remember, that is to say, at the outset, Freud’s disparaging remarks – disparaging about both his most inspired follower, and about the wish to cure – in his infamous obituary for Sándor Ferenczi, his colleague and collaborator, in 1933. ‘After this summit of achievement,’ he wrote, ‘it came about that our friend drifted away from us … the need to cure and to help became paramount to him.’ As though the wish to cure and help someone was itself a betrayal, a misunderstanding of psychoanalysis. This we might take as an emblem of Freud’s ambivalence about the concept of cure in relation to psychoanalysis. If you want to stay in the psychoanalytic fold, the wish to cure and help must not become paramount. This rather starkly dissociates psychoanalysis from medicine, and indeed, from the so-called helping professions.

After proposing that there was ‘a definite and progressive theory of cure in the writings of Freud’, Khan then cites, perhaps predictably, Freud’s famous remark in Studies on Hysteria (1895) that, ‘much will be gained if we succeed in transforming [your] hysterical misery into common unhappiness’. Hysterical misery is caused by the conversion of unacceptable representations of desire into bodily symptoms. ‘Common unhappiness’ is the unhappiness involved in acknowledging the impossibility and the conflict of such desires. It is certainly far from therapeutic evangelism in the apparent modesty of its aims. And yet, even though common unhappiness – common human unhappiness, as it is sometimes translated – is something we can all too easily recognize, we can still notice Freud’s commonsensical omniscience about what life is really like. We could ask, for example: common to whom? Or unhappy by what standards? Once again we see Freud taking refuge from psychoanalysis in a mythical realism, an assumed consensus: psychoanalysts, like everyone else, only know, and know about the people they actually know (which is why psychoanalytic writing about so-called human nature tends to be grandiose and misleading). Khan comments rightly that it was ‘a revolutionary step in the process of cure’ at the end of the nineteenth century to, as he puts it, ‘identify and credit’ the psychiatric patient with unhappiness. ‘Up till then,’ he writes, ‘the psychiatric patient had been treated either as a bizarre object of social ridicule, or as a nuisance to be manhandled by medical procedures into apathetic compliance.’ What I want to stress, alongside Khan’s appreciative acknowledgement of Freud’s instinctive kindness, is Freud’s instinctive fear of the psychoanalysis he was inventing. His practice was, to use Khan’s word, ‘revolutionary’; he had recognized and revealed the hysteric’s astounding capacity for alternative forms of representation only to suggest that, at best, psychoanalysis could help the hysteric get back to normal.


Copyright © 2021 by Adam Phillips