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90THE XXIV WORLD CONGRESS OF PHILOSOPHY. CHINA. BEIJING. PEKING UNIVERSITY 13-20 AUGUST, 2018
Э.М. Спирова
ЗДОРОВЬЕ И БОЛЕЗНЬ: ПСИХОАНАЛИТИЧЕСКИЙ ПОДХОД
Аннотация. Бурное развитие технологий, происходящее в современном мире, обязывает пересмотреть традиционное сопоставление нормы и патологии, сложившееся еще в классическом психоанализе. Фрейд постоянно подчеркивал относительность границы между здоровьем и болезнью. Существуя параллельно, они взаимодействуют друг с другом. Каждое действие одновременно происходит на двух уровнях — соматическом и психическом. При этом во многих случаях З. Фрейд говорит не столько о взаимодействии души и тела, сколько об их взаимопроникновении. Таким образом, психическое здоровье оказывается тесно связано с телесным. Между тем биотехнологии вносят коррективы в эти положения. Они позволяют преображать тело, но не соотносить эти «исправления» с психическими и духовными факторами человеческого существования. В статье особое внимание уделяется культурно обусловленным представлениям о здоровье и болезни, анализируются проблемы современной европейской медицины в сравнении с восточными практиками.
Ключевые слова: психоанализ, здоровье, болезнь, тело, психическое здоровье, невроз, человеческая природа, культура, целостность человека, бегство в болезнь.
Elvira Spirova,
chief research fellow, Institute of Philosophy, Russian Academy of
Sciences (Russia, Moscow), [email protected]
HEALTH AND ILLNESS: A PSYCHOANALYTIC APPROACH
Abstract. The rapid development of technologies in the modern world necessitates revision of the traditional comparison of norm and pathology that has g taken shape in classical psychoanalysis. Freud con-| stantly underlined a relative character of the bor° der between health and illness. Existing in parallel, ^ they interact with one another. Each action occurs © simultaneously on two levels — somatic and mental.
In many cases Freud speaks not only about interactions between soul and body, but rather about their interpenetration. Therefore, mental health is closely related to the bodily. Meanwhile, biotechnologies introduce their corrections into these statements. They permit to transform the body, but not to correlate these «corrections» with mental and spiritual factors of human existence. The article pays special attention to culturally conditioned ideas of health and illness, analyses problems of contemporary European medicine as compared with oriental practices.
Keywords: psychoanalysis, health, illness, body, mental health, neurosis, human nature, culture, human integrity, flight into illness
Psychoanalysis deals, first of all, with man's mental, psychic health as distinct from his neurotic disorders. The founder of psychoanalysis Z. Freud con-
sidered human health from the positions of coherent, harmonious functioning of his psychic apparatus. In the work «Analysis Terminable and Interminable» (1937) he pointed out that health cannot be described except in terms of metapsychology, as the dynamic relations between the institutions of the psychic apparatus the existence of which has been discovered, conjectured.
The purpose of psychoanalytic therapy is to alleviate suffering of a patient who came for help to the analyst and make him healthy, capable of conscious and responsible solutions to intrapsychic conflicts. But this does not mean that the analyst should by all means be striving to get the patient healthy. There are cases when the analyst has to admit that the patient's mental illness, his conflict ending in neurosis, is a harmless and socially tolerable solution. As Z. Freud pointed out in the «Introductory Lectures on Psy-cho-Analysis» (1916/17), the analyst should not restrict himself to being a «fanatic in favour of health» in every situation in life. The physician should take into consideration that necessity may require a person «to sacrifice his health» and this sacrifice of one person «can prevent immeasurable unhappiness for many others» (Freud, 2012).
Z. Freud was one of he first scholars to indicate that the border between health and illness, the normal and the abnormal is relative. He wrote to his favourite pupil Karl Abraham: «We all have these complexes, and we must guard against calling everyone neurot-ic». To his other favourite, Sandor Ferenczi, Freud wrote the following: «A man should not strive to eliminate his complexes but to get into accord with them: they are legitimately what directs his conduct in the world».
According to Freud, only primitive man can be called mentally healthy in the strict sense of this word, since, unconstrained by cultural demands, with which modern man must reckon, he can satisfy his natural strivings and wishes. For most people there is a border-line, beyond which their constitution cannon follow the demands of culture, meant for the average man. Paying attention to this point, in the article «"Civilized" sexual morality and modern nervous illness» (1908) the founder of psychoanalysis remarks: «All who wish to be more noble-minded than their constitution allows fall victims to neurosis; they would have been more healthy if it could have been possible for them to be less good». It is under the influence of culture suppressing man's sexual desires that most people become neurotics or, in Freud's opinion, even lose their health.
Freud's ideas of health have found further interpretation in psychoanalytic literature. Some psy-
choanalysts concentrated on the possibility of natural satisfaction of man's sexual instincts as the main criterion of mental health (for instance, W. Reich (Reich, 1997)), others took into consideration socio-cultural conditions of life predetermining healthy or unhealthy development of an individual (for instance, K. Horney (Horney, 2016)). E. Fromm raised the question about the necessity to revise the traditional conception of mental health, according to which that individual is considered healthy, who adjusts himself to the requirements of society (the notion of health from the standpoint of society), since society by itself can be «sick». As opposed to this conception, he called for return to the ancient humanistic tradition which determined human health proceeding from the development of individual life forces (the notion of health from the standpoint of an individual himself) (Fromm, 2015). Later psychoanalytic doctrines advanced along the way of studying «illnesses» of modern civilisation, in which man is compelled to exist.
But can we attain recovery without having clear demarcations between what is called the normal and what is the abnormal? An individual ideal of health may diverge from the social norm toward both sides. An individual might think he is not healthy when society is sure of his health, and on the contrary, he might think he is healthy whereas society refers him to the category of sick individuals. Specially crippled children in V. Hugo's novels were perfectly fit for the social role of comedians. On the other hand, Hamlet, who tries to put time to rights, is announced mad...
Developing this theme, some authors come to the conviction that health has many models. Pushkin's Boris Godunov is not complaining of health but he is tormented by throes of the spirit, the «beast with claws» bears a morbid condition. In the 19th century, psychiatrists believed that schizophrenia affects those who are at odds with their conscience. But today we know that an intrapsychic conflict of great force can knock down even a moral individual. The spiritual awakening of Quasimodo from V. Hugo's novel «The Hunchback of Notre-Dame», who has enormous physical strength, makes him suffer from his deafness and deformity.
Since man is ill, the way to health also depends on many social commitments. Ancient people believed that any cure begins with setting mental states to rights. That is what shamans and ancient mystae did. Even in the Middle Ages cure was associated with exorcising the demons. During the Renaissance the right to perform body autopsy was obtained at last. Physicians could see internal organs of the human body. Gradually, a new trend appeared in medicine. Dis-
covery of the cell and other scientific achievements resulted in association of health, first of all, with the body. Now a human being is more and more often viewed as a mechanism with varied links between the organs. Henceforth, not the body in general is treated but its particular organs, which, physicians or patients believe, need therapy.
But what is the difficulty here? Today the ideal of health is mainly associated with the body's physical condition. However, the border-line between norm and pathology is extremely unstable. In the physiological sense, medicine is incapable of determining the content of a norm be it blood sugar or pressure. Besides, an individual is not only a physical body. He also has a soul and spirit, he is a social being. Health is a natural phenomenon, for there is no culture that would regard as healthy an individual without arms, legs, or affected by leprosy. At the same time health is a social phenomenon. In antiquity, a healthy man was a well trained athlete, since that was the time of the cult of the body. In Medieval culture, the status of a healthy individual could be given to a puny, impoverished ascetic following the path of spiritual enlightenment.
All these paradoxes could be strung endlessly. The multiplicity of health standards have brought some authors to hold that health is a social artefact, inseparably linked with social (medical) technologies. But can we accept this viewpoint? Whatever be the way to health, a human being is still a natural being. Nowadays for assessment of a human being we often use the same measurement instruments as for machines. Contemporary medicine proceeds from the postulate quite appropriate for a technical society: for an individual to be able to function, his body parts should be fine-tuned. It is very much like equipment checkup with subsequent adjustment or replacement of particular organs, be it the heart, kidneys, breasts. There seem to be no organ that couldn't be substituted. We cannot but ask: what is «human proper» about man that cannot be replaced without a risk to bring down human nature?
Certainly, we can understand health through the social construction of this concept, nevertheless, more precisely see a paradoxical combination of the ideas of «naturalness» and «artefact» in the phenomenon of health. Also, we should point out the existential sense of the notion of health: each period of time raises the question about the nature of illness and the essence of health in its specific form. But this does not mean that each time man's historically specific «nature» is invented. In illness as a fundamental existential threat man turns to his origins.
How indeed can we translate theoretical reasoning into the clinical aspect? Probably, here some considerations about man's integral nature might be helpful. Many authors write today that man should be understood in his integrity. As we have already noted, no object can be assessed as either integral or fragmentary. In fact, there are particular wholes that can be viewed as fragments of another, more developed whole (Gurevich, 2004). The conceivable whole is but a scheme of some idea with which we operate. Why doesn't man as a whole become an object of study for us? Any attempt at creating man's integral scheme is doomed to failure.
We shall remember: to a degree to which the scheme is in conformity with truth, it will certainly manifest its particular, not comprehensive character and point to just another way of partitioning the «human». Man's integrity is not a given entity but an ideal, a driving motive for a breakthrough to being. Man is not integral in principle, his being is torn, full of collisions. But man has a general opportunity to acquire the fullness of his existence. Integrity becomes a problem for man, his perpetual striving, an individual attainment of harmony. Man might remain fragmentary, one-dimensional, fundamentally torn.
Man is a being without his niche. However, it is not a sign but a contradiction of our being. All man has seems to negate itself. He has instincts but they are not unfailing stimulators of behaviour. Man rules over nature, and at the same time becomes its «deserter». He has some fixed signs but they are ambiguous, since they escape final definitions. Man has a tragic understanding of the ways of his existence and at the same time in each individual, i.e. in himself, discovers this truth all over again.
The earliest definition of health is attributed to Al-cmaeon: health is a harmony of the opposing forces. This formulation has many followers up to the present. According to Cicero, health is a state of happy, mutual relationship of the different psychic states. The Epicureans and Stoics valued health above everything in their opposition to enthusiasm, to the exceptional and the dangerous. The Epicureans believed that health is complete contentment with a measured satisfaction of every need. The Stoics regarded every passion, every manifestation of feeling as illness; their moral doctrine to a considerable extent was a kind of therapy aimed at elimination of diseases of the soul in favour of a healthy ataraxia. Nietzsche stated that healthiness as such does not exist.
But if health criteria are so difficult to define, may be it would be easier to define illness? Illness is breakdown of health, a flight (complete or partial) from the
state of health. Karl Jaspers offers such definitions of illness: 1) a disintegration into opposites, an isolation of opposites, a disharmony of forces; 2) affect and its consequences; 3) disingenuousness as, e.g., a flight into illness, an evasion or method of hiding. (Jaspers, 1998, p. 940). In the beginning of the last century the definition of illness as «hiding» proposed by the psychiatrist V. von Weizsäcker was actively discussed: «When an individual in difficulties acquires the respectability of an illness and a social reaction is converted into a pathological symptom some falsification of meaning has taken place which provokes our respect for truth to some criticism... The neurotic achieves an act of concealment and betrays this through his guilt feelings. We have also often seen a flare-up of guilt feelings in non-neurotic, organically ill people. They fight with themselves in the prodromal stages as to whether they should give in or not or during convalescence whether they should remain ill or not.» (Jaspers, 1998, p. 940). Von Weizsäcker therefore argues «that health has something to do with genuineness and ill-health with disingenuousness». (Jaspers, 1998, p. 940).
Psychiatrists of the past believed that the innocent never go mad, only the guilty (J. Heinroth) and that moral perfection and mental health are equal (F. Groos): if the innate drive towards the good develops freely, no physical event can call forth a mental illness. Here, too, belongs Klages' conception, according to which psychopathy is suffering brought about by self-deceptions that are vital to the person's life.
Speaking of the paradoxical nature of «illness», V. von Weizsäcker stated that «severe illness often means the revision of an entire life-epoch» and thus in certain contexts illness may have a «curative», «creative» significance. He also emphasized the significance of the law «whereby the removal of one evil gives place to another». The harmony of opposites is a limiting ideal but it is not a concept of what actually is and not a possibility that could hope to be fulfilled. Ataraxia and contentment bring an impoverishment of the psyche and disturbances arise from all that has been passed over and neglected.
Z. Freud paid much attention to the phenomenon of «flight into illness», regarding it as a way of replacing a lack of satisfaction realised through reverse development (regression), return to earlier forms of psy-chosexual life that used to give satisfaction. A solution to an intrapsychic conflict through the formation of a neurotic symptom is a convenient and desirable outcome for an individual who does not want or cannot make the difficult and tormenting work of overcoming the conflict situation which would necessitate a significant strain on his physical or mental forces.
Such a strategy proves to be advantageous for him, due to retreat into neurosis he receives internal benefits from illness, to which an external advantage is added, since the patient received sympathy from people around him, can avoid unwanted responsibilities. Here we see regression to the infantile stage of life.
Therefore, when we look at life either as a state or as a process (i.e. the flow of life processes in their entirety) we differentiate deviations from the average (anatomic anomalies, malformations, absence of iris pigment, etc., and physiological anomalies such as pentosuria) and deviations that belong to life as it flows (the disease-processes proper). Being free in our judgements from the evaluative element, we can distinguish the patient's concept of his illness as a mere value-judgement from that of the doctor's concept which is a total concept of what concretely is — based on an idea of what is average.
K. Jaspers specifies the following difficulties of this approach.
In the majority of people we can find phenomena such as dental caries, which though an average finding are called 'unhealthy'. There are such deviations from the average as exceptionally long life, great physical strength and powers of resistance which one would never label as 'sick'. In this connection, it would be necessary to introduce a third category of «super-healthy» alongside those of «sick» and «deviation».
In fact we can practically never establish the average in the case of the living human body. Such ascertained averages are mostly confined to anatomical measurements. The notion of the «average» is almost never known.
Western medicine due to its mechanical orientation is not inclined to acknowledge the spiritual force which is a principal element of the Eastern thought. In the East, attention is focussed on preservation of health, not on treatment of a disease. This requires an integral, comprehensive approach to health, alien to western medicine. Everywhere in the East, health is the state of the balance, harmony between the individual and the cosmic. This principle underlies the practice of taiji-quan, a kind of exercise therapy oriented to attainment of a sense of unity with the universe through performance of slow movements. The same principle is present in meditation practiced to calm down the mind in order to feel the inner spirit and unity with the universal spirit. The balance and harmony are also inherent in the two great forces called Yin and Yang. These two forces, one of which is associated with earth and the other with heaven, should be balanced in an individual as they are in the universe. Disease can be regarded as absence of a balance between them.
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