the narcissistic difficulties presented to the observer by the psychosomatic problem

The narcissistic difficulties presented to theobserver by the psychosomatic problem1

Pierre Marty

Dealing with psychosomatic realities often generates narcissistic neurotic resis-tances in the observer that form an obstacle to carrying out scientific work. Thetendencies towards schematization and the enforced investigation of arbitrarilydefined objects of study, such as they appear in some theoretical standpoints, areaspects of these resistances. The self-destruction evoked by the problem of the‘death drives’ in its superficial dimension constitutes an obstacle of the same kind.

In my report a few months ago on our clinical investigations of some cepha-lalgia patients, I gave a detailed observation of Marie’s case. When the timecame for questions from the audience, Dr Nacht put to me the followingquestion: ‘‘You talk about cephalalgic neurosis, but could we not put thismore simply by saying that your patient had a neurosis, maybe a character-ological neurosis, and some cephalalgias?’’

I believe that the problem could not be more clearly framed.My paper that day had been entirely based on the interconnections

between Marie’s neurosis and her cephalalgias. I had demonstrated the com-mon energetics, with the shift in the defence against the mother, alternatingbetween the algesic and the neurotic level.

The development of Marie, her family environment, her neurosis and hercephalalgias formed a complete entity in which it was impossible to isolateeither a neurotic or an algesic or even a social element without shatteringthe edifice of Marie’s personality. There was nothing surprising in the obser-vation, and its key elements could be explained and dissected, except for thepoint of transition from the neurosis to the cephalalgia, even though thiscomprises a point of particular value. Furthermore, Marie got rid of herheadaches without our having addressed this transition point. And howmight we have been able to do this?

The exact point at which the affective is transformed into the somaticremains an unknown factor, as it is still is in psychosomatic studies.

Freud referred to a ‘‘leap’’ (1909, p. 157; 1917, p. 258). The observableattempts to localize the ‘jumping-off point’ do not in any way exclude in myview – but I emphasize this understanding as my view – the possibility ofsomething that resembles a ‘leap’.

In fact the neurosis and the somatic problem, as well as the common ener-getics, are evident, but it is difficult to see how the transition is made fromone quality of energy to another. Although we can manage without this in

1This paper was presented at the Paris Psychoanalytical Society, 24 March 1952.Originally published as «Les difficult�s narcissiques de l’observateur devant le problem psychosomatique»in Review FranÅaise de Psychanalyse, 1952, pp. 339–357.Translated by Sophie Leighton.

Int J Psychoanal (2010) 91:347–363 doi: 10.1111/j.1745-8315.2010.00250.x

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�e International Journal of

the treatment, the hiatus is undeniable and raises the question: ‘Can we notsay that there is a neurosis and some cephalalgias?’

However, posing this question seems to be an attempt to separate some-thing that was combined, to try to return something unified to what wemight call a dualist conception.

Now, and this is above all where the problem escalates, the works of DrNacht, who even refers to ‘organic’ masochism, clearly demonstrated –before I developed an interest in psychosomatic studies – a perspective withwhich I entirely agree. Furthermore, Dr Nacht points out in one of hispapers on psychosomatic medicine that: ‘‘The Freudian influence hasabolished the concept of duality between psyche and soma’’ (translatedquotation, italics in his original text).

The answer I gave Dr Nacht that day was in fact just as strange as thequestion posed, since it was expressed in the following terms: ‘‘Yes, funda-mentally we might say that there is a neurosis and some cephalalgias’’.

I think that we can conclude from this that this rather empty dispute con-tains a pitfall, a difficulty that was certainly long ago emphasized, butremains undeservedly unexplored. This difficulty consists in my view first ina crucial problem of vocabulary or language, and then in an individualproblem in the mind of each observer.

I shall attempt to obtain a closer view by using the classical clinical exam-ple of the stomach ulcer.

In examining an ulcer patient, there are four important kinds of fact canbe observed:

1. Social facts. These exist in the childhood family situation and are thefoundation of the genesis of neurosis. In the present, they constitute aspecial environment that is specific to the patient and, for the ulcerpatient, they are as well adapted to him as he is to them.

2. Neurotic facts. These emerge from the above. They regulate a behaviourthat maintains an atmosphere and, to a great extent, a reality, a familyand social ‘formula’ as just observed. Furthermore, these facts exist ina close relation with the stomach pain.

3. Physiological facts at the gastric level. We know about hypermotricity,congestion and hypertonia. This hyperfunctioning is closely connectedwith the neurosis. It is also connected with the lesion, the ulcer itself.

4. Histological facts. These include both the lesion and the cellular role inthe hypersecretion.

There are therefore four different levels – social, neurotic, organic and his-tological – with manifest interactions. The specialists in each of these levelswould demonstrate much more thoroughly than I could the links betweenone particular element and its hierarchically adjacent elements.

There are some close interconnections, interplay and vicious circles thatmake the stomach ulcer – to put it cautiously – an apparently inextricablesocio-neurotico-somatic syndrome.

Clinically, we observe a patient with intermittent stomach pains. He suf-fers in periods of oral or affective frustration, that is, when he is presentingonly his genital potency or its equivalents. But he escapes from the social

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situation he has thus created; he cannot tolerate it. He sets about makinghimself loved like a child. The pains cease when he has reconstituted a socialor family environment, a climate adapted to this regression. This new situa-tion, experienced as a castration, proves no more tolerable than the previoussituation of oral frustration. The patient therefore escapes it only to revert tothe first. And so this is where the life of the ulcer patient immediately begins.The four kinds of facts or levels described above are constantly interacting.

This impression of an inextricable syndrome, which appears difficult toaddress, is not confined only to ulcers or to psychosomatic syndromes. Inobserving any kind of neurotic patient, we see identical interactions betweenthe environment and the individual. These interactions have conditioned theemergence and development of the neurosis and condition the very form ofsociety in which the neurotic patient develops and that he seeks out. Forpsychosomatics, it is evident that the problem only broadens and that phe-nomena belonging to more archaic evolutionary levels come into play: theorganic and even the cellular level in relation to the stomach ulcer thatI have taken as an example.

How do we proceed in analysis in the case of a straightforward neurosis?We demonstrate to the patient, through the transference and the dialogue,how he is behaving. And once the analysis is concluded it becomes apparentthat family and social problems, previously inextricably entwined with theneurosis, have practically ceased to exist. The social problem has assumedits place and his difficulties are no longer anything but objective, forinstance, financial. The Gordian knot has been cut, and theoretically we cansee the boundaries of the various problems that still arise.

The analysis is the same for the stomach ulcer patient; but the problem ofthe connections between the neurosis and the surrounding social constella-tion is compounded by the problem of the connections between the neurosisand the gastric functioning and, further along still, the cellular level.

When the analysis is concluded, not only has the ulcer patient’s socialproblem returned to its level, but the organic gastric problem has returnedto being an organic problem of the stomach. It has also returned to its leveland, if any further difficulties of this nature arise, they too are ‘objective’.

In other words, the alimentary problem, for example, still exists for thestomach, as does the problem of financial difficulties for the cured neurotic,but this no longer has anything to do with what preceded it. The problemsare more straightforward, and any social, affective or somatic factor nolonger reacts to any social, affective or somatic factor. The various elementsexist at their respective levels; in very general terms, there has been a shiftfrom pathology to physiology.

As I have shown, addressing one particular level – that of the neurosis –in analysis was enough to return not only the affective problems to theirplace, but also the various elements of the previous and later evolutionarylevels. It is the same as when a piece of a jigsaw has been fitted in, and allthe other pieces fall into place around it, almost as a matter of course.

However, this does not mean that the connections between these variouslevels have disappeared. It is only the focus of interest that has changed.The gastric problems are now only nutritional problems that can be solved

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by the individual, essentially in his relations with society. Financial problemsare of the same kind. Altogether, everything as a rule comes down to theindividual’s relations with society, and the individual has taken the placethat seems to belong to the human being at the evolutionary highpoint,without preoccupations and wasted energy subsisting at lower levels, evolu-tionarily bypassed at the human stage in which the essential activity is social– the activity of establishing groups and hierarchies between human beings.

I present all this in an ideal and, of course, an excessively rigid way.Things are obviously much more relative in reality, and I believe we neverobserve this situation of the ideal human as being understood only in theevolutionary sense and wasting no energy in deferred difficulties that areusually called regressive.

As I have just shown, in the unattainable norm, as in pathological life thatis always more or less in doubt, the close link between the various somatic,psychic and social levels – not to mention others – constantly exists, andthese levels themselves only exist in relation to each other, without everbeing possible to construe and examine in isolation.

It is somewhat strange to find that we analysts, who constantly see therelations between neurosis and society, namely in the family genesis of theneurosis, and the way in which the neurotic person maintains and seeks outa particular social atmosphere, can be in any doubt about an identical linkexisting, only at a lower level, between our organic functioning and ourmental activity, when we are constantly being confronted with abundant evi-dence of their reality.

Then there is the acting out that moves what we would like to maintain atan affective level on to a muscular or another level, or the many visceralmanifestations, genuine flights, that our patients indicate to us in the courseof their treatment. Are the very foundations of neurosis, its energic source,the drives, not essentially organic? Are the main stages in the neurotic per-son’s development – oral, anal, phallic and genital – not designated by thesame adjectives as those used to refer to organic centres?

That being so, how can we conceivably pose the question of how we canknow whether there is any relation between the neurosis and the cephalal-gia, especially when we have all the evidence of it before our eyes, when wehave just seen nothing but that!

This would not be a serious problem if it did not, as it often does, gener-ate only a vain and sterile discussion concerning the word ‘psychogenesis’,which has little practical benefit since we do not define or limit the conceptof thought, which is obviously difficult to do, since thought derives from atissue that is not yet thought and extends its branches into social relationsthat may no longer constitute thought.

However, it seems to me that the problem does become serious when weask how we can know whether it would not be simpler to consider thatthere is a neurosis and some somatic problems because it wastes time and,above all, reveals our inherent incapacity to detach ourselves from certainforms, the deep intransigence of some of our perspectives, our instant retreatfrom psychosomatic problems in particular and our difficulty in keeping our

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attention on the essential aspects of these problems, as if we were carryingout these studies despite ourselves, against ourselves.

I believe this is what accounts for the scarcity or poverty of psychosomaticworks, the detachment or lack of attention to them and the disengagementthat often follows the fleeting interest inspired by psychosomatic medicine inmany doctors. This is despite the evidence of its existence provided at everymoment of our lives, including at a personal level, by the psychosomatic knot.

These difficulties are in my view deeply rooted in narcissistic neurosis.I do not wish at the outset to suggest that our own individual narcissism

is responsible for the entire burden of our difficulties in this matter. I havealready emphasized the importance of the linguistic problem.

Moreover, I do not think these two questions can truly be separated, for thestatic, formal and imagistic state of language seems to me primarily a phylo-genetic reflection of the narcissistic problem, which itself remains ontogeneticand individual. Language cannot be used without regard to its defects anddangers, but also the advantages it presents for sliding and drowning ournarcissistic tendencies deep inside it, and camouflaging our responsibility. Theconstant ‘‘alienation of speech’’, in Jacques Lacan’s felicitous phrase (Lacan,2001, p. 235), may too often be the screen for our own alienating tendencies.In any case, having noted the above, I shall return to the problem of narcis-sism, which can be tackled without any reference to evolution.

It is to Lacan that we are indebted today for a deeper knowledge of anentire dimension of the origins of narcissism and the key role of the ‘mirrorstage’.

I can do no better than to borrow from this author some sentences froma masterly account of the narcissistic problem, in a style that is probablytaxing, but has a richness that sometimes manages to submerge the formal-ism of language in its approach to fleeting and shifting reality:

This jubilant assumption of his specular image by the child at the infans stage, stillsunk in his motor incapacity and nursling dependence, would seem to exhibit in anexemplary situation the symbolic matrix in which the I is precipitated in a primor-dial form.

(Lacan, 2001, p. 2)

He continues:

But the important point is that this form situates the agency of the ego, before itssocial determination, in a fictional direction, which will always remain irreduciblefor the individual alone …

(pp. 2–3)

Later on he states:

The mirror stage is a drama whose internal thrust is precipitated from insufficiencyto anticipation – and which manufactures for the subject, caught up in the lure ofspatial identification, the succession of phantasies that extends from a fragmentedbody-image to a form of its totality that I shall call orthopaedic – and, lastly, tothe assumption of the armour of an alienating identity, which will mark with itsrigid structure the subject’s entire mental development.

(p. 5)



The primordial individual conflict that emerged from the confrontationbetween the imagery and the reality of the mirror stage is often rediscoveredin the endless meanders of its evolution and it hollows out the principalfoundations of the neurosis.

Here I will emphasize only three aspects of the narcissistic problem posed,which will later serve my argument, namely:

• the crucial importance of the visual function in what we believe to bethe approach of reality

• the exclusive belief in the spatially defined object• the difficulties attached to the idea of the fragmentation of the body

and the possible disappearance of its image

Each of these three aspects has a corollary that proves to have primordialimportance in the psychosomatic study and can be expressed as follows:

• Psychosomatics deals with invisible and unschematisable functions.• It has no spatially defined object.• It extends the notion of regression through the mental functions to

somatic disease, that is, to the attack on the body and to its annihilation.

I shall examine each of these three points in turn.

I

I believe there is no need to emphasize the role of the visual function at thecrucial time of the mirror stage and the importance that the individual willfrom then on confer on what he believes to be the evidence of the reality offacts, when in fact it will be only a representation, an image tarnished byillusion and error.

The disappearance of the object from the visual field, whether it is thebreast, the mother, faecal matter, the penis or the love object, remains oneof the essential foundations of neurosis at the various stages of both itsdevelopment and its genesis. The belief in the individual’s participation inthe world in the visual objectal mode revealed from the mirror is a crucialfact with the modalities that have been demonstrated by Lacan.

Once beyond this stage, accepting the existence of a non-visual realityprobably amounts unconsciously for most human beings to denying the pre-cise nature of their body, to minimizing it or accepting its fragmentation.

I believe that there is an obstacle at this point that we never completelyovercome and that constitutes one of the bases for rejecting the reality ofpsychosomatic connections.

Turning to examine the various scientific fields and juxtapose their objectsfrom a general perspective, we are struck by one essential difference in therespective quality of these objects, namely their capacity for visual, schematicand graphic representation, in a form other than written language, even morerigid than speech, which is in fact already known to be dangerously inflexible.

In some physics and chemistry studies, for example, the images or sche-mas retain all their value, and correspond so closely to the reality of theobject that they target that it is even possible to predict the kind of confron-

352 P. Marty


tation that will occur between the two objects, their joint movement, namelythe relation in physics or the chemical composition. Accordingly, the atombomb was known about before it existed.

In biology studies, however simple their object, such as the single-cell organ-ism, every image, schema and graphic representation has already ceased to beof much value. The object, the cell, has itself become a movement, a function,a set of functions, and any attempt to schematize this movement can only leadto dealing with partial representations, such as those of particular tropisms ormetabolisms, but this has very little value precisely because it is the representa-tion of the result of an artificial fragmentation in which there is nothing to begained by assembling these schematized parts. The study itself can be basedonly on the observational experiment, and the predictions generally prove tobe very remote from reality, without it having been possible to consider certainfactors in advance. Accordingly, the effects of the atom bomb on animalorganisms have only been addressed after experimentation.

The biological movement evidently contains all the movements that pre-cede it in evolutionary terms, but time and space have already long sinceceased to be the sole coordinates, hence the impossibility of any valid gra-phic schematization. The spatio-temporal movement has expanded ordecreased. I am somewhat inclined to favour this second term, for at thebiological level time and space continue to impose their laws and theincrease in quality of the biological movement, of the function, in relationto the straightforward spatio-temporal movement, seems to be mainly dueto the contribution of new restrictions and laws.

Moving further along the evolutionary scale to the psychic domain, it isquickly clear that psychic functions have almost entirely ceased to be basedon forms and that their graphic representation, however remote, is almostimpossible and totally unproductive.

The movement that was straightforward at the physicochemical stage hasbecome strangely complex, to the detriment of visual representation of theobject. The molecule could be drawn. The cell could be drawn in its frag-mented aspect. The thought can no longer be drawn in any of its elements.

Loewenstein thinks that ‘‘mental energy cannot be expressed in spatialterms, since what is mental exists only in time and not in space’’ (1940, p.396). I must admit that I do not understand exactly what the second part ofthis sentence means. I do not think that, because a spatial representation isimpossible, something cannot belong to the spatial system. Furthermore,I do not believe that there is any great practical benefit to theoreticallyexcluding the concept of space.

To return to psychosomatic problems, not only are they intrinsically resis-tant to graphic representation due to their intermediary level betweenunschematizable biological facts and even less schematizable psychic facts,but this difficulty with their graphic representation is compounded for tworeasons: on the one hand, because psychosomatics seems to be a structurethat is only apparently the linchpin between the two words; on the otherhand, because psychosomatics is a young science in which the humanbeing’s imperturbable tendencies to schematize in graphic, that is, visual,form have so far had very little time to be exercised.



The need to schematize, to give objects a form, even when it is evidentthat they do not have one, is found throughout the development of the sci-ences. There is no question of rejecting it – the benefits of schematizationfor manipulating concepts are well known – but this is no reason for us tooverlook their only very relative value and the affective dimension thatbecomes permeated with our narcissism, often without our knowing it.

Schematization consists in the division of reality into isolated forms thatno longer have anything but remote connections with reality.

Some learned surgeons recently told me that at one particular moment intheir physiological works, which were in fact based on visual, measurableand measured reality, they had managed to demonstrate that it was impossi-ble for blood to circulate. Although there is little risk of committing such anerror here because error quickly becomes apparent, the same does not applyat the level of thought.

In the field of psychiatry, we have often observed and still do often seethe tendencies to get entangled in exclusive beliefs in forms, in divisions ofthe individual into mental functions that can be separately measured.

The use of tests, for example, although offering practical advantages thatare familiar to everyone, has only relative value in assessing the patient,since it only takes account of him in terms of fragmented aspects. Theapparent stupidity of cephalalgic patients in clinical practice has beenobserved. The Rorschach test has also been found to be incapable ofbypassing this false stupidity. Batteries of tests have been created, but thisdoes not overcome the hiatus between the forms and the reality. Using thesetests, moreover, often results in time being wasted and a larger number oferrors than can be produced by an extensive clinical examination.

Particular attention must nevertheless be paid here to these criticisms ofthe value of certain methodologies and even some more or less formulatedpsychiatric theories in relation to psychosomatic medicine. The only usablemethodology for addressing and studying psychosomatic facts is necessarilypermeated by the experience of the classical psychoanalytic method.

The minimal training necessary for the psychosomaticien doctor is to beanalysed.

However, all this is far from perfect. Psychoanalysis has not escaped thetendency to reduce sets of phenomena that are perpetually in motion toforms that without being spatial nevertheless still have a static quality.

I am thinking of topographical references, especially here the id and theego. I believe it is necessary to have a great deal of analytic experience toventure to use these terms confidently, without fear of being misled by theirformalism. Even this does not eliminate the danger of their use. Freud indi-cates to us, specifically in The Ego and the Id, ‘‘the difficulties that arisewhen one begins to take the spatial or ‘topographical’ [note the emphasis]idea of mental life seriously’’ (1923, p. 19). Loewenstein also tells us that‘‘the topographical system of reference should, I think, be handled withespecial caution in depicting and explaining mental phenomena, precisely onaccount of its spatial character’’ (1940, p. 387).

At the last Congress of French-Speaking Psychoanalysts, Lacan againemphasized in a humorous way the relative value of these references.

354 P. Marty


The danger of spatial representations implicitly incorporated in thissystem appears obvious in addressing psychosomatic manifestations.Topographical references seek, in order to facilitate discussion, to apply andproject on to the individual sets of phenomena that belong to different levelsas a reality of the same evolutionary level.

Freud identifies the relativity of the value of topographical references bydemonstrating the origins and extensions of what they represent. Heexpresses this to us in The Ego and the Id in a paragraph I will nowquote:

It is easy to see that the ego is that part of the id which has been modified by thedirect influence of the external world through the medium of the Pcpt.-Cs.; in asense it is an extension of the surface-differentiation. Moreover, the ego seeks tobring the influence of the external world to bear upon the id and its tendencies, andendeavours to substitute the reality principle for the pleasure principle which reignsunrestrictedly in the id. For the ego, perception plays the part which in the id fallsto instinct ...

(Freud, 1923, p. 25, my italics)

Despite having then shown us in these few lines the many interconnectionsbetween the various elements of reality, Freud again feels the need toemphasize the relative value of each when he concludes this paragraph asfollows:

All this falls into line with popular distinctions which we are all familiar with; atthe same time, however, it is only to be regarded as holding good on the average or‘ideally’.

(p. 25)

If Freud addressed the clinical study of various psychosomatic manifesta-tions, I believe there would be few risks of error. But usually, it seems tome, topographical references are not deployed with all the precautions thatwere taken by their creator.

Now, to use the notion of the id without any view to its roots in the drivesand the soma is not only to address psychoanalytic problems inadequately,but also to reject from the outset psychosomatic problems, which are inlarge measure rightly constituted by studying the infrastructures of the idand their extension through the id into the most external strata of the indi-vidual.

I therefore believe that the vocabulary inherent in the topographies mustbe avoided as a precaution – or with every term explained in each instancein psychosomatic analysis – for I think (as experience has shown me) thatthis vocabulary is often used in a sense that necessarily bars the way toinvestigation, leading the study at the outset down a path that is necessarilyblocked.

Psychosomatics deals with functions that are invisible, unschematizable.The invisibility of these functions comes face to face with our tendency toschematize into various forms without which we have great difficulty accept-ing reality. This difficulty is inevitable, but we keep in mind their deepermeaning: spatial representation and schematization are ways in which ournarcissism intrudes itself into our research.



II

Our need for spatial, graphic representations is the transposition of our nar-cissistic need to see ourselves and only to believe in our body and then inourselves if we can see ourselves. It is only a general dimension of the prob-lem, which also has specific aspects.

Lacan demonstrated that the mirror stage was the explosion of a dramawith a long gestation. The unity, integrity and volumetric limitation of thebody assume a crucial value in the individual’s eyes at this point.

The notion of our bodily unity and integrity, of our own limitation by theimage of our body in the mirror, by what we might call the topographic ref-erence to ourselves, is not confined to this personal level. It extends into ourknowledge system as a quest for evidence of universal reality and on thisnew basis it creates a new difficulty in psychosomatic studies.

Most sciences consist in the study of apparent spatial unities, objects withdefinite forms, whether in physics, chemistry and their related fields, or thenatural sciences, botany, zoology, medicine and their related fields, and theirspecializations, such as bacteriology, pathological anatomy, gastroenterologyor ophthalmology.

The work consists in studying the object, the unity, the spatial form in ques-tion, such as the eye, from a viewpoint that is first static and morphological,then functional and then analytical of its constituent unities and movements,their related functions and then the eye’s connections with the higher unity,the specific individual whose eye is one of his constituents. These are, ofcourse, artificial divisions, but every incision, every part, corresponds to adefined image that is, firstly, anatomical and, secondly, physiological.

The relations between the principal unity – the eye in ophthalmology –and its constituent unities and the higher unity of which it constitutes onepart, are the essential object of study.

Until now the sciences have been based on volumetrically defined objectsand the relations between these objects, the cell’s relations with the tissue,the tissue’s relations with the organ and the organ’s relations with thehuman being as a spatial entity. I should immediately state that merelyreplacing the word ‘organ’ with the word ‘function’ does nothing to alterthe observer’s narcissistic difficulties.

But psychosomatics, which also incorporates the objects of study ofpsychoanalysis, appears in a different light from that of the sciences that wehave just listed. In fact, although psychosomatics consists partly in the studyof the somatic, the drives and what we have called the infrastructures of theid, it also extends through the psyche to the individual’s relations with apart of the external world.

Now, neither the psyche nor the external world is based on objects thatare limited in space, and our tendency to seek security systematically in thevisible object has been exercised and still is exercised in these areas, withreason but often generating passion and error.

I will move on quickly to the localizations of the psychic apparatus andthe tendencies to base it on an object. We all know about the heroic age ofextreme theories of cerebral localizations. But this trend is not over.

356 P. Marty


In his report to the First World Congress of Psychiatry, concerning thegeneticists’ localising theories, DuchÞne told us:

Henri Ey has long emphasized the striking similarity with this problem of cerebrallocalizations, much more familiar to psychiatrists, in which a mechanistic solution isnecessarily followed by a dynamist reaction, and the criticism of the ‘cerebral cen-tres’ by Monakow and Mourgues – ‘The wish to localize spatially a process thatoccurs in time is itself a localization’ – could be applied to the geneticists’ ‘genecards’.

(1950, p.)

The problem also exists in relation to attempts at spatial localization ofthe external world, although it is not usually considered from this perspec-tive.

We certainly have some ideas concerning the human being’s belonging tohigher formations, or, we might say, higher groups, for we sense and knowthat the essential aspect of these forms is constituted by social forms: inclu-sion in the mother, then attachment to the mother, then to the family, thento various forms of societies.

We should not deny our successive belongings to these social forms, buttheir definition, the status of their reality, raises a problem as soon as thenewborn is physiologically separated from his mother.

The essential relational function of our belonging, our bond with socialgroups, if it is not entirely congruent with what is called the psychic appara-tus, is in any case often very close to this psychic apparatus. It is enough tosee the connections between thought and language to observe that languageis exactly that: the function of the human being’s relation with his fellows inan evolutionary perspective of group formation.

I believe that we could benefit from doing only what we do in analysis:observe and, following observation, note the individual’s various bonds andbelonging to social groups. But although this attitude is a rule in analyticpractice, I do not believe it is always a rule in research, in which someattempt to limit and predefine the social setting and group to which theindividual must be made.

The underlying basis of some political theories and social theory systemsoften seems to me to be precisely situated in an attempt at spatial localiza-tion, an arbitrary demarcation of the situation and status of the group andan enforced imposition of this definition. And once again on this subject,passions are evidently stirred by localizing theories.

Now, this insecurity problem created by the fusion of social forms andtheir lack of effective limitation consists above all, I believe, in the observer’sown narcissistic insecurity and necessarily pervades scientific investigation,giving it an arbitrary appearance.

In this sense it also pervades the kernel of the error, given that psycho-somatics touches on social functioning through what is called the somaticand the psychic.

The localizing tendency has already taken hold of psychosomatic medi-cine, seeking out an object of its own, and the diencephalohypophysialcrossroads is sometimes accorded the status of a linchpin, a magical



point at which energy undergoes a qualitative transformation. It is clearthat this has only a very limited value and, although the diencephalicregion often plays a very important role in psychosomatic relations, theproblems largely transcend the narrow framework of this domain in mostcases.

Moreover, to get a firmer idea more generally of the meagre benefits, inreality, of all these attempts at localization that we observe, we only have toreturn our attention to the evolutionarily bypassed forms.

I have just observed that there are some articulations between elementsthat are more or less evolutionarily close, such as between the cell and thetissue, the tissue and the organ. Examining these elements, it is quicklyapparent that the form of each amounts to little, and that this element isitself the centre of many articulations and so on without formal, spatial real-ity ever being of great interest. The cells that form the various tissues of theeye are the seat of physicochemical reactions that depend on a mass of con-nections with the neurological, hormonal, circulatory, digestive, affective andsocial systems. The benefit of the spiral demarcation of the eye disappearswith the progressive knowledge of the entire interplay of connectionsbetween functions of which it is the centre – we can no longer say theobject. The same applies to every constituent of the eye, the tissues andcells. It is also the same for the psychic apparatus and the human being. Itis probably the same for social groups that we want to limit.

I was just saying that the evolutionary movement proceeds to thedetriment of the object. There is no doubt that the objects encountered inpsychosomatics are not the essence of the problem.

It is precisely at the very moment that the object is eliminated, and thatforms and levels are merged in a movement that links the physiological withthe social through the psychic, that psychosomatics is situated, which is asecond reason why our narcissism is ill adapted to this study.

III

I will swiftly proceed to consider the third point. The medical sciences adoptdifferent a priori positions towards illness, according to whether this is so-called general medicine, traditional psychiatry or psychosomatic medicine.

Disease is always ultimately considered, that is, unconsciously from theoutset for the individual, as the loss of an object resulting from the fragmen-tation of the body. This reveals the close link with the narcissistic formulaethat have been considered.

The attitude adopted towards illness by classical medicine is to seek a patho-genic factor that is external to the ill individual. The illness is the result of anexternal attack, caused by physical, chemical or biological agents at an evolu-tionary level that is always below that of the human being.

There are two attitudes in traditional psychiatry. The first is that taken bygeneral medicine: the external agent creates the functional or lesional dis-order that underlies the mental illness and remains its cause.

The second attitude takes the movement in the opposite direction in anevolutionary perspective: the social organization is pathogenic and creates

358 P. Marty


the mental illness, but it all remains confined in a domain from which thebody seems to be excluded.

Psychosomatic medicine is usually thought to derive from this secondpsychiatric attitude. The starting-point is emotional (the emotional emergingfrom the social) and the illness, the regression, extends to afflicting theindividual’s body in its functioning and then in its substance. The theoriesconcerning the choice of organ more or less attenuate this rigid attitude,which still fundamentally persists.

Rejecting the idea that external factors are chiefly responsible, for the firsttime psychosomatics essentially postulates that the individual is capable ofdestroying his body himself, in part or entirely, and that this is no longer onlyin a theoretical way as in the neuroses but in a practical and effective way.

It is not my intention here to discuss the value of this postulate. Theproblem is crucial, however, as it concerns the existence of the death drivesand their real meaning; but there will, I believe, be an opportunity to returnto this problem on other occasions.

I now only want to emphasize that psychosomatics directly proposes theidea of actual self-destruction. This idea implies the fragmentation of thebody and the disappearance of its image due to the individual himself. Itallows the possibility of the subject destroying the object, with both charac-ters remaining improbably united.

As Loewenstein rightly told us on this subject:

No longer to speak of ‘instincts’ when we are referring to the general trends towardslife or death which we call Eros or destruction … seems to me all the more preferablesince it is difficult for the imagination to conceive such a thing as an instinct of death –such a thing, that is, as an energy whose characteristic it is to strive to destroy the verything from which it proceeds. It can only have a meaning if it is regarded as a trendtowards a lowering of the level of energy, in which case it would fit in with Freud’s def-inition of it as a trend towards reducing life once more to an inorganic state.

(1940, p. 384)

Whatever the case may be, psychosomatics refers to actual self-destruc-tion, which is a third reason why it can only disturb the observer in hisdeepest strata.

I have sought in this paper to emphasize just a few of the narcissisticdifficulties that are almost forcibly imposed on us in turning to studypsychosomatic problems. I do not consider that these difficulties can beresolved through the impossible solution of the classical philosophicalproblem. After the above-mentioned paper on psychosomatic medicine,Nacht answered his interlocutors:

I said at the beginning of this paper that the problem of psychosomatic medicineshould not reignite the sterile old dispute between the organicists and the psychoge-neticists, between the monists and the dualists. The discussion that has just takenplace proves that this was inevitable.

(1948, p.)

This problem was my starting-point, but my aim was to transcend it andtranspose this general question to a more clinical level, by bringing it backto the problem of the narcissism of the observer, that is, of each of us.



I consider three points to be essential in this matter:

• our tendencies towards schematization, towards visual representation ofa reality that is invisible and unschematizable

• our tendencies to seek to base on a spatially defined object biological,psychic and social facts that largely transcend their supporting frame-work

• our tendencies, finally, to deny that there is any self-destructive energyin ourselves

All these tendencies are certainly neurotic rather than philosophical.I have sought to demonstrate their meaning. They exist only to the extentthat we pose false problems; they manifest in the fact that we have posedfalse problems and have been attached to them. This is the same as in allthe neuroses.

Clinical practice is always there, however, to bring us back to reality andshow us the futility of our forays into the other domains.

Psychosomatics is not merely a hyphenated compound word or concept, itis the study of evolution centered on a long ‘moment’ of which the limitsare indefinite. There is no reason to suppose that this ‘moment’ possessesany kind of magical property. Its lack of boundaries, its imprecision, mustnot be allowed to hinder our studies.

We must know how to wait in what we believe to be indeterminate inorder to find our position, and to accept what we believe to be imprecisionin order to address better the precise nature of reality.

References

Duchene H (1950). Rapport de discussion, section VI. Premier Congres Mondial de Psychiatrie.Paris: Hermann.

Freud S (1909). Notes upon a case of obsessional neurosis. SE 10: 151–318.Freud S (1917). Introductory lectures on psycho-analysis. SE 16.Freud S (1923). The ego and the id. SE 19: 1–66.Lacan J (2001). Ecrits: A selection, Sheridan A, translator. London: Routledge.Loewenstein R (1940). The vital or somatic instincts. Int J Psychoanal 21: 377–400.Marty P (1951). Aspect psychodynamique de l’etude clinique de quelques cas de cephalalgies. RevFr Psychanal 1: 339–57.

Nacht S (1948). Introduction a la medecine psycho-somatique. L’Evolution psychiatrique, fasc. I.

360 P. Marty


Discussion concerning Dr Pierre Marty’s paper

Marie Bonaparte’s contribution

We can’t get away from narcissism! Psychosomatics itself is rooted in narcis-sism. It is narcissism to believe in our self-destructive powers! There seemsto have been, on the individual level, something of what is happening on thecollective level, what is happening for the psychosis of the year 2000, as ourlate colleague Schiff called this monumentally narcissistic notion that humanbeings were powerful enough to blow up the planet with an atom bomb!

M. Held ’s contribution

My warm congratulations to Dr Marty for his fine lecture and the skill withwhich he has climbed from the specialized clinical terrain, familiar mainlyfrom our hospital practice over the last several years, to the highest summitsof knowledge itself. I freely admit: until now it had hardly occurred to meto apply to the field of psychosomatic medicine a methodology that provesso necessary in addressing the major problems of biology and psychology,which are both concrete and analytical in their epistemological aspects.

This leads me to wonder if, to return to the title of the paper we have justbeen given, the narcissistic difficulties encountered by the observer inpsychosomatics are specific in nature or whether this is merely a fact of avery general kind. Now it certainly seems that identical difficulties appear inwhat are reputed to be the most exact sciences. There are very few theoriesand experiments into which the observing subject’s affectivity, and particu-larly his narcissism, do not intrude.

In numbers theory (do mathematical entities exist beyond the countingand calculating mind?) in the transition from deductive mechanics and a pri-ori to experimental mechanics, for example, in extending the application ofCarnot’s second principle (of the depletion of energy), narcissistic resistanceslong delayed the acceptance of a science that casts doubt on the unity andeternity of matter (see L. Brunschvicg, 1972, Les �tapes de la philosophiemath�matique, p. 305 et seq.). A fine example of narcissism was given by thelate Lecornu, a member of the Institute, professor of applied mechanics atthe �cole Polytechnique. In a discussion of Einstein’s theories at the Acad-emy of Sciences, Lecornu indignantly exclaimed (or approximately – I quotefrom memory): ‘We don’t want any of those theories here coming to upsetour old mechanics’, revealing his narcissistic anxieties about the disintegra-tion of what had always founded his self-construction as a man of science.This brings to mind what our master and friend Leuba said about thosepatients who rebel violently against their analyst’s chaotic undertakings atthe beginning of the analytic treatment to which they have apparently sub-mitted of their own free will.

As it seems to me that Marty was referring to certain ‘political’ aspects ofnarcissism, I am tempted to add in turn that certain forms of ‘social conser-vatism’ also conceal fears of the personality itself disappearing entirely or



partly along with the established social order to which it tightly ‘clings’.What difficulties, there too, for the would-be objective observer!

Furthermore, I cannot see why the ‘psychosomatic leap’ should raise aquestion that can be isolated from what might boldly be called all the other‘epistemological leaps’ that appear for us to negotiate. Even to pose thisquestion, to imagine that we can resolve it either with a dualist hypothesisor a simple or dual aspect monism (to adopt Guiraud’s expression) is tocommit the sin of narcissism. It is to postulate a final apprehension of real-ity when ultimately this is always the human mind that observes and thinks,and cannot know anything of this reality but ‘successive interpretations’, cer-tainly ever more subtle and precise, but never anything else. For example,I believe that the somatopsychic leap – namely, how after a certain numberof mitoses a human egg can present us with the view of the figure of aspeaker expounding his ideas on psychosomatics to listeners who were them-selves born after some equally strange embryological adventures – alsoengages some intense narcissistic resistances. It is these that will partly deter-mine the orientation of our beliefs, making us sometimes take comfort intheism and sometimes take refuge in the apparent security of a fashionableneo-positivism.

Although the human being’s intrinsic narcissism certainly enters into thesight of the ill person, it is at the body of the dead human being that itmanifests in its purest form. The rejection of the leap into the void, and thedesire to ‘leap into a world beyond’, saving something of our ego, could bean abundant source of material for many delicate discussions. But this isneither the moment nor the place to leap from psychosomatics on to suchhotly disputed ground. Nevertheless, there too – what narcissism!To conclude, without misunderstanding the real heuristic value of the work

Marty has presented to us, I will wait until I can read it at my leisure to tryto understand better his reasons for choosing psychosomatics as the domainin which to discern some specific narcissistic difficulties, as well as how toovercome them in my everyday practice. In this way, I hope to be able toincrease my therapeutic efficiency.

I have one last comment to make on a point of clinical detail. The gas-tric ulcer is the type of illness that is characterized by progressive upsurgespunctuated by intervals of clinical silence. We sometimes see ulcer patientsceasing to suffer without the slightest change appearing in their relationswith other people. The pain also reappears in the same conditions. We alsosee patients in whom the progressive upsurges coincide very precisely withthe reactivation of certain external conflicts. We must therefore be verycautious in assessing purely affective factors and bear in mind that everypatient (with an ulcer or tuberculosis) rests more and takes better care ofhimself in general (the opposite can in fact be the case!) when he is feelingill. Once cured, he soon forgets. This process affects many morbid rhythms.Of course this in no way contradicts the dynamism of the underlying psy-chopathological processes, but it further complicates the clinical picture.We might perhaps envisage here a sort of ‘organic cyclothymia’, a visceralderivation of a functional alternation in the humour centres, invisible orscarcely visible through the usual thymic manifestations.

362 P. Marty


M. A. Hesnard ’s contribution

Since Pierre Marty (who deserves every compliment for the brilliant accountto which he has turned his detection of the observer’s narcissistic prejudiceagainst the psychosomatic object) has proclaimed – beneath his philosophi-cal originalities – his fidelity to clinical practice, it is as a clinician thatI shall make an observation: as I pointed out at the Congr�s des Ali�nistesin Rennes and in a recently published paper in the Strasbourg Cahiers dePsychiatrie, there is a confusion concerning psychosomatic medicine. Thereare some common illnesses, indisputably emerging from general pathology,which follow an accumulation of depressing causes, affective factors such asmourning, especially failures, random ethical circumstances, and in individu-als who have never previously manifested any neurosis nor even a neurotic‘constitution’ or ‘character’. This is not only attested by clinical practice,but, when they are subjected to a deeper analysis, no conflict can be recon-structed in them other than those found and perfectly tolerated in so-callednormal subjects.

However, these individuals do reveal some genetic factors of the kindstudied by psychoanalysis. But when they can be detected (which is some-times impossible), they go back to an extremely early developmental stage –such as certain traumas, shocks or events that disturb behaviour in themonths (or even days) following birth. Digestive pathology is a particularlyrich source of facts of this type. Not being fixed by visual memory, theseare somatic or visceral behaviours that demonstrate their psychic nature bytheir (apparently normal) revival in the adult. Hence the unreality of psyche-soma dualism, a mythical vestige of metaphysical body–soul dualism. Atthe recent conference of French-speaking psychoanalysts, I found myselfentirely in agreement here with our London colleague, Mrs MacAlpine,whose experience relates in fact mainly to the dermatoses. She pointed outto me some other cases in which the physical disease is a kind of organiclanguage that expresses the adult’s currently established conflicts and in theabsence of any classical neurosis and, particularly, of any sign that mightindicate a hysterical conversion.

This language of the body, sometimes with a meaning relating to currentconflicts and sometimes having lost its past meaning (dating from a vegeta-tive era), refutes all dualism – or rather leads us to accept that dualism onlyexists in the method used to observe human facts: objective observation(transposed from physiology to the fact of behaviour) or phenomenologicalobservation based on the observer’s identification with the observed. Inshort, the person has a unity and the approach to him is dualistic.



the narcissistic difficulties presented to the observer by the psychosomatic problem

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