**4. Relationship between psychoanalysis and psychiatry**

As we have seen, both men seek to enrich psychiatric care. They agree on its insufficiency. Yet the diagnosis about the nature of this insufficiency differs.

For Freud, this insufficiency stems from the fact that psychiatry dilutes the etiology of disorders into a benevolent generality (which he identifies, sometimes, with philosophy):

• because she does not observe meticulously enough:

*"Psychoanalysis has roughly the same relationship with psychiatry as histology has with anatomy; one studies the external forms of organs, the other the tissues and the basic parts of which these organs are made."* [6]

• because it favors a heredity which intervenes like a Deus ex machina and especially scotomizes the fact that " there is family and family " and that, sometimes, the family itself can be pathogenic:

*"Why is the content of delirium in our case precisely jealousy?4 (...) Here we would like to lend an ear to the psychiatrist, but it is here that he leaves us in the lurch (...) He will search in the family history of this woman and will give us the answer: delusions arise in people in whose family similar mental disorders have occurred on several occasions. If this woman developed a delusional idea, it was because she was disposed to it by hereditary transmission."*

And Freud concludes that both disciplines are complementary... For Binswanger, more radical, psychiatry squarely misses the patient, his illness:

*"By the development of our psychiatric task, we deviate more and more from the concrete reality of the psychological person. Two paths are open to us:*


*Now, it must be admitted that these two conceptions have no immediate relation to this concrete reality which we call the psychological person. These are detours on the person-to-person route".* [10]

<sup>4</sup> *Id.* Freud has just described in a woman a case of extreme jealousy which is in fact explained by a repressed fondness for her son-in-law.

It is therefore necessary to modify not the approach of the disorder but that of the patient and to recontextualize the evil in the becoming of the subject, even to make it a lever for healing:

*"Illness is a moment in the patient's life history"* and again: *"Illness is the expression of the normal course of life"* [5]*.*

However, for Binswanger, ambitious in the ends but too modest in the means, this mutation of psychiatry can only occur by way of internal growth while for Freud, it must proceed to the definitive importation of an external form which it is originally lacking.

For Freud, psychiatry is sick. Sick of his silences and his procrastination. For Binswanger, it is stationed at a functional stage which keeps the patient in the shade, it prevents him (and prevents itself) from growing. Time is requested, more time:

*"Freud,* he wrote, *always underestimated the difference in structure between the two disciplines… and imagined my role as mediator too easily…" (id.)*

Controversy on the nature of the libido and the drive, contestation on the omnipotence of the id and in particular on a self-sufficient structure of the Ucs which generates both the forces which create and unite and those which destroy and disperse: these are the main stumbling blocks between the Binswangerian and Freudian approaches, approaches which, let us repeat, will diverge even more after the death of the Viennese master. However, beyond this divergence, and even the radical separation represented by the death of Freud, it is clear that the medical collaboration between the two men remains intact.

#### **5. Clinical experience and therapeutic practice**

Both men in fact agree on a capital point: because the etiology resides in the patient, the cure can itself come only from him:

*"We can certainly understand what happened to the patient,"* Freud notes, *"but we have no way of making the patient himself understand it."*

Of course, we are still far from any notion of working-through, but with the recognition of transference and counter-transference, the alchemy that is established between patient and therapist appears to be the key to real progress. Now this key is practice which alone can provide it.

#### **5.1 The scope of the psychoanalytic method**

*"My conviction as to the exceptional therapeutic efficacy of psychoanalysis "in appropriate cases" has in no way been affected by this criticism",* writes Binswanger in his *Memories* [5]*.*

He will admit later that, of the eighty patients housed in his establishment, only twenty are in analysis, most of the time those for whom he cares directly (the clinic has five to six doctors).

The question which arises here is that of knowing for which cases Binswanger reserves an analytical treatment, that is to say those to which the application of the analytical grid leaves the hope of a real therapeutic success.

#### *5.1.1 The problem of semiology*

The first question is that of the symptom and its interpretation. As we have seen, the status of the sign and of the language, not only spoken but symptomatic, is

#### *Freud and Binswanger: An Asymptotic Relationship DOI: http://dx.doi.org/10.5772/intechopen.94882*

not the same according to the systems. For Binswanger, the question of the "crazy sense" also arises in a deficient language configuration.5

But the question is also to know what, "in" the analyst, interprets. Freud of course, with reference to the mechanisms of transference and countertransference, warns Binswanger against the idea that, in order to better understand the analysand, it would be necessary to involve his own unconscious. But for Binswanger, this restriction, if it is the pledge of scientific objectivity, hinders the establishment of co-routing between doctor and patient towards a common world, the ultimate goal of "therapy" and of "infinite" healing.

He wrote to Freud6 : *"You must admit all the same that there is a unitary mental predisposition common to all men and that if this predisposition works without being hindered, "understanding" is established by itself. But precisely this "of itself" is problematic for me.* And Freud replies: *"My proposal to appreciate the analysand's Ucs as a receiver was formulated in a modest and rationalistic sense, but I know that it conceals important problems".*

This depersonalization (or deindividualization) of the Ucs will be at the origin of a recourse, first as a security then as a surety, to the resources of the hermeneutics of Schleiermacher or Dilthey to found a kind of co- analyst-analyzer hermeneutics, a solution that Binswanger preferred to the Jungian one of a collective unconscious.

But Binswanger's universalizing approach is already like the prodrome of a dissolution of the concept of Ucs as part of a patient's own life story.

#### *5.1.2 Neuroses*

When the disorder manifests a deregulation of the course of the libido by a defense mechanism whose the ego, an intact ego but which perceives itself as threatened, is both the stake and the agent, recourse to the analytical approach appears as fully legitimate. According to Binswanger, it is here that psychoanalysis has demonstrated its undeniable effectiveness. But in all their protocols, Freud as well as Binswanger remain essentially pragmatists: *"Freud is and remains the conscientious explorer of nature, who does not say more than experience gives him".*

Starting from the theme of female jealousy, we have, in an earlier article,7 tried to show from a clinical case how the Binswangerian doctrine is established as a simple extension of the Freudian doctrine.

In Freudian doctrine, jealousy, that is to say the delusional construction of the desire of the other in relation to a third party, is interpreted first of all as a defense mechanism in relation to one's own (unacknowledged) desire. We can refer here to the text of the conference on "Psychoanalysis and psychiatry" (1915), subsequently integrated into the *Introduction to psychoanalysis* and to: "On the transformations of the drives, particularly in anal eroticism", published in 1928 in the *Revue française de psychanalyse*, II. The case cited by Freud is that of a woman who suspects her husband's infidelity when in fact she herself desires her son-in-law.

<sup>5</sup> To stay as close as possible to the truth here, we must recognize that Freud admitted: *"In schizophrenia, it is the predominance of the word relation over the thing relation which gives the symptom its surprising character" Métapsychology*, The Unconscious, VII, The recognition of the Ucs. But he adds: *"This investment represents the first of the attempts at restitution or cure thereby excluding a virtually pathogenic character of language."*

<sup>6</sup> Letter of February 15, 1925. Freud's response arrives - belatedly - in Nov. 22.

<sup>7</sup> This is the case of Ellen West, a case of anorexia, later reclassified as schizophrenia. The article entitled "Freud and Binswanger" appeared in the *Swiss Archives of Neurology and Psychiatry*, I, 2016.

In a second step, the man is identified with the penis, a penis which one wishes, in a regressive and exclusive mode, to keep permanently.

Later, Freud established a link between jealousy (and any form of possessive love) and anal eroticism directly related to the containment of feces. The anal stage is a stage where certain primitive features of love take shape (retaining it and giving it, the risk of detachment from oneself, of loss of the loved object ...).

Finally, as we have seen, he will extend this doctrine to the genesis of psychoses through his doctrine of narcissism.

Except on the ultimate development which aims to link homosexual anal eroticism to the constitution of a narcissistic, jealous or melancholic and potentially paranoid ego, Binswanger shows himself, on all these questions, in agreement with the Freudian interpretation. However, based on his own clinical experience, sometimes shared with Freud (the case of J. v. T. mentioned in the 1910 correspondence or that of Mme F, mentioned in the 1912 correspondence - two cases of repressed homosexuality -), sometimes isolated - that of the Ellen West case - he developed his own theory at that time. Thus in Ellen West, being-in-the-world is first of all being-in-body. However, this body is perceived as a round body, isomorphic to the earth, while it is moreover structured around the void and the hole of the anal orifice but also of the mout and therefore the reverse of the terrestrial world, a ball of matter enveloped in the celestial void. This is the "crazy meaning", all woven of metaphor, that must be deciphered in order to understand Ellen, in particular her doctrine of oral then anal fertilization, her anorexia - as a rejection of the "lie" (no concealment or projection therefore here) - and finally, her suicide as a return to the void and to the hole of the grave from which will perhaps take place another, quite another germination (passion for gardening). We find also this mouth-anus system at Louis Wolfson (*Le Schizo et les langues*, Paris, Gallimard, 2006).

As we can see, the pathogenesis here is structured by something much more than an excessive defense mechanism which would lead to the dissimulation (by projection for example as was the case in the Freudian interpretation) of a repressed libido. On the contrary, it is about revealing and showing. We encounter a similar mechanism in Jürg Zünd, when he manifests - through the wearing of thick coats in the middle of summer or of a suspensorium - in his pathological fear of making the erection visible, that there is, precisely, nothing to hide. Faced with the indecipherable darkness of the drive journey: the blinding light of the human condition.

But in passing, we can clearly see that Binswanger left the framework provided by the psychoanalytic grid: it is precisely the whole condition of man that constitutes the mainspring of neurosis, its "knot", insofar as this condition is not contradictory, by the fact of internal struggles between two orders of drive, but radically incomprehensible. It is the world which lodges in the sign of contradiction, neurosis is only a way of saying it: *"Anality in the psychoanalytic sense is the fragment of a global world of the hole, that is - that is to say a fragment of the carnal part of the proper world"* [11]*.* It no longer refers, therefore, to a type of repressed pleasure or even allowing to escape, as a passive structure, from a psychosis by a semi-identification with the womanmother, it refers to a global conception of being-in the world.

Here is announced the project of an anthropology, medical if you will, philosophical if you prefer, to rethink the whole of the psychiatry of neuroses or, for cases like that of Ellen, this which will become borderline personality disorder (Binswanger will speak, in 1921, of *schizophrenia "simplex"*).

#### *5.1.3 The case of psychoses*

However, if this enlargement severely relativizes the framework of the Freudian analysis, it does not affect its therapeutic efficacy. It is not the same in the field of

#### *Freud and Binswanger: An Asymptotic Relationship DOI: http://dx.doi.org/10.5772/intechopen.94882*

psychoses. Apparently, there are at least, for the psychoanalyst, two entries in this field: the sexual and the infantile. However, this turns out to be insufficient.

The Freudian analysis, as we have seen, is in fact based on the conflict between the libido and the ego, a marked conflict, Binswanger will note, by the personalization and dramatization (of psychic instances).8 But it is precisely this notion of me which, in psychosis, is missing.

The therapeutic strategy in Freud consists in reinforcing the ego even if, in order to do this, he must recognize the presence and the strength, at its borders, of an Ucs who, ceaselessly, contests them. But when we approach the field of psychosis, this ego purely and simply evaporates.

*"In the region of what really gave,* Binswanger notes, *we do not meet any me! What astonishment when we then see what is given in a unique way, for example the drives (…) becoming metaphysical, "mythological" or psychological elements building an ego"* [12]*.*

Of course, Freud is not far from reaching a similar conclusion when he speaks of a narcissistic involution of the ego or what amounts to the same thing, of a *"libido which does not seek a new object but withdraws into the ego"* [2], an ego which in the end does not manage to build itself because it remains trapped in the ego of the first figure of attachment. But, here again, the risk of misunderstanding is great because if, for Binswanger, psychosis in fact expresses the absence of the ego, this message must in some way be interpreted positively, and not as a confiscation by the libido or by a mother-world.

Let us take the example of Jürg Zünd, subject to "all phobias" and an "apparent delirium of reference" [11]. He has built a world-project in which at any moment a break in balance can occur, in particular a contraction of space which, suddenly, brings my body closer to other bodies in a violent or even fractal fashion. Where the psychoanalyst would see an etiolation of the ego or, to use a term used by Binswanger himself, a "shrinking" of the ego in the face of a hypertrophied world, Binswanger is content to describe this world-project as the very one. Which *constitutes* Jürg Zünd.

Admittedly, Jürg Zünd has a libido, a sexuality (distancing from women of modest extraction) and this sexuality is indeed the object of a singular treatment since it must be, at the same time, carefully hidden. and openly exhibited. But it is only a language intended to show the veiling of Being - or to reveal its abscondity and this starting from the zero point where space expands/contracts: the body.

It would be the same with Lola Voss, in her delirium of persecution [11]: for Lola Voss it is not a question of rebuilding an ego involved in the rejection of contact with the other but of re- "worlding",9 with the help of the practitioner, even if she populates her new world-project with ambushed assassins who watch or stalk her relentlessly.

The reconstitution of an ego "master of the house" can in this case be of no help. In reality, it is the ego and the individuation and subjectivation processes that it induces which is pathogenic. Absolutely pathogenic. We must stick to being-in-theworld and its sharing: *"The distinction between existential analysis and psychopathology concerns the* who *of being-in-the-world"* [10]*.*

We then understand that the famous concept of nostrity, which some have considered sometimes foreign to Daseinsanalyse and to the psychiatric doctrine of

<sup>8</sup> This observation results from the numerous notes reporting on the progress of volume II of the *Einführung in die allgemeine Psychologie*, volume it seems almost entirely written but never published and to this day lost.

<sup>9</sup> This neologism tries to translate the specific term of "welten" which remains outside of the idea of creation but of an opening projected of the Dasein (M. Heidegger, *DerUrsprung des Kunstswerkes (1936)).*

Biswanger, is, in reality and in every respect, a psychiatric concept. It has nothing to do with an We which would be born from the meeting between two self-consciousnesses even if, in the texts and in particular in the *Grundformen*, Binswanger often uses both terms by giving them an equivalent meaning. It is the original structure of Dasein like *Mitsein (being-with)* and only the return to it, in and through illness, can "heal".

It is therefore not wrong to say that the thought of the ego evolved in Binswanger, passing from the contestation of an instinctual origin (with a stiffening in the Kantian transcendental I), previously mentioned, to its pure and simple negation in a no less original nostrity. This second position, however untenable in therapeutic terms (faced with the risk of transference, the patient-doctor distance must remain) will itself crumble in recent years and *Wahn (Delirium)* (1965), for example, restores, after the long Heideggerian detour, the hypothesis of a husserlian transcendental ego.

But Freud also evolves and his thought, especially that of psychosis, marks if not a rapprochement with Binswanger's thought, at least the taking into account of his preoccupation. Thus the reciprocal influence of the two thoughts appears more and more clearly.
