Microsoft word - edith - traduccin articulo - sndrome tourette.doc

INTEGRATIONS FOR A PSYCHOLOGY WITHOUT BODY AND
A NEUROLOGY WITHOUT SOUL
Edith Liberman


Its usual among us to state the theoretical or the conceptual deficiencies of the
Bioenergetic Analysis and the necessity to build up sufficient theoretical framework to
support our way of working.
Do we have to invent a new theory?
How can two categories that have developed separately, two paradigms, the mind and the
body, whose knowledge have taken different ways, can be connected to each other?
The same dilemma, that one of mind and brain, has been brought up to the Neurologists
when they look for the subject in the brain functioning. From the clinical point of view the
way for the integration that the Neurologist Oliver Sacks chooses, facing this dilemma, can
be useful for our own theoretical dilemma.
The interaction between body and mind is the main subject of the identity of the Bioenergetic
Analysis. It is what makes us different from other analytic, cognitive or behaviourist
psychotherapies and at the same time our added value, from our point of view, with respect to
psychoanalysis, our conceptual father.
But it is also our major challenge, as this incorporation of the body to the frame of
psychotherapy must be done on the basis of a sufficiently solid theory and technique to give
sense to our way of working. In many occasions we have the impression that our theoretical
basis for this integration is insufficient and I am sure that it is so, as historically the studies of
the psychological matters and the biological matters were divided, when not opposite, giving
origin to different conceptual models: the biological and the psychological paradigm. So much
so that it has also given rise to different professions: physician and psychologist, psychiatrist
and psychologist, neurologist and psychoanalyst.
We are not the first nor the least ones to suffer this integration difficulty. The effort to come
closer to the connections between the biological and the psychological matters concern
nowadays to part of the physicians and psychologists and the investigation about brain
functioning and the psychology of emotions is providing some answers, although they may be
provisional, to a field in which up to now we only found questions.
As we all know, Reich was the pioneer, coming from psychoanalysis, in the incorporation of the
body to psychotherapy. He was the first one to develop certain Freudian assumptions that
indicated an investigation and work direction that, however, Freud himself did not continue.
Lets mention some of these assumptions: “The ego is first of all a body ego”, “Anatomy is the
destiny”, and the economical matter, quantitative of the instincts, for example.
In his 1st topic, Freud began the building of a model in which the biological subject was still
very present, the same as in his first works with Charcot about hysteria. Grant me the
permission to say that in these writings Freud still worked as a doctor.
However, this direction of the investigation was not developed and, to say it someway, Freud centred/focused his sight on the contents and not on the container. The study of the container is the field of neurology and Freud investigated the contents of the psychical system. In this way its comprehension became more and more abstract, and in that abstraction it was more difficult to maintain the connection with the material part, the body and its biological functioning in this case. That is what Oliver Sacks, an identity neurologist, refers to when he speaks about the development of a psychology without body. Exactly the same process but in the opposite sense, continued the classic neurology in the study of the brain functioning. The studies of the cellular structure, of its psychology, of the specializations of the different parts of the brain and of the localization of the functions, which were done starting from the alterations produced by diverse diseases, withdrew in practice, the neurology of the contents, from experience. They withdraw the disease from the patient, the brain from life. This is what Sacks calls a neurology without soul. I was introduced to Oliver Sacks’ work by chance and I was interested in it and afterwards in other authors of his same line for two reasons: 1st due to his methodological approach 2nd due to his studies about building and maintenance of the own identity when biological factors, that is to say neurological diseases, hinder or threaten it. Psychology takes care of puzzling out the construction of identity from the environmental point of view, the relationships of the person in its environment during the growing up stage and the way in which these early relationships give place to a binding and behaviour pattern. It also takes care of unravelling the learning processes and of mutual influence and interaction between relationship patterns with their emotional contents and learning. Psychotherapies take care of facilitating the integration of the ego, for which it is necessary that the identity is a stable and at the same time flexible construction. That life difficulties do not represent a threaten, but that adaptation resources permit facing the reality impacts (conflicts, losses, shortages) maintaining the homeostasis, the equilibrium and the integration of the personality. Sacks’ work is centred in observing in which way neurological catastrophes affect the identity maintenance and also describes the alternative creative procedures, that the characters develop to try to maintain the identity facing the catastrophe, to maintain the ego integration. Sacks describes cases in which the disease destroys or limits memory, perception, senses, the symbolizing capacity, the capacity to modulate impulses, and the way in which patients, with more or less success, try to compensate these alterations to be able to continue knowing who they are, knowing what is around them and managing to function in reality in a way that has sense and results being liveable. Going through Sacks’ work we can recognise in patients with a neurological disease, alterations that we find in another extent in our own patients without any neurological disease. And so, understand and discover the biological dimension contained in the personality. Due to the limited time and space of this article/report I will limit myself to set out shortly the subject in which the neurological disease produces a syndrome known by us from the psychological approach and I will try to compare both approaches. I chose the Tourette Syndrome, which Sacks calls “the missing link between body and mind”. But before entering totally in this case, I would like to dedicate one moment to the first aspect from Sacks I was interested in, the methodological aspect, as I find there useful elements for our own methodology and theoretical drawing up in Bioenergetic Analysis. If we look at the programme of our Conference we observe that we mostly have clinical expositions, expositions of cases. The 5 books of neurology I know from Sacks are also expositions of cases preceded by a theoretical introduction. His investigation methodology and why he writes books about cases is explained in this introduction. And says: The patient’s essential being is very relevant in the higher reaches of neurology, and in psychology, for here the patient’s personhood is essentially involved, and the study of disease and of identity cannot be disjoined. Such disorders, and their depiction and study, indeed entail a new discipline, which we may call the ‘neurology of identity’, for it deals with the neural foundations of the self, the age-old problem of mind and brain. It is possible that there must, of necessity, be a gulf, a gulf of category, between the psychical and the physical; but studies and stories pertaining simultaneously and inseparably to both—and it is these which especially fascinate me, and which (on the whole) I present here—may nonetheless serve to bring them nearer, to bring us to the very intersection of mechanism and life, to the relation of physiological processes to biography. (1987, p. viii) Being a doctor, a neurologist, Sacks worked 20 or 30 years in hospitals, diagnosing diseases and prescribing medicines, looking for the most adequate drug in each case for the treatment of the disease. But as time passed by and particularly due to his work in an institution for chronic patients, whom he saw progressing day after day, he arrived to the following conclusion: “The study of disease, for the physician, demands the study of identity, the inner worlds that patients, under the spur of illness, create. But the realities of patients, the ways in which they and their brains construct their own worlds, cannot be comprehended wholly from the observation of behaviour, from the outside.” And he adds: “In addition to the objective approach of the scientist, the naturalist, we must employ an intersubjective approach too, leaping, as Foucault writes, ‘into the interior of morbid consciousness, [trying] to see the pathological world with the eyes of the patient himself’” (1995, pp. xviii-xix). Now, here we find an important methodological question. To see from the exterior is the classic scientific position. But, according to him, it is not sufficient, as it does not allow us to know those inside worlds, psychological we would say, of the patient… And consequently, understand in which way the neurological disease, the biological alteration, modifies, affects and is produced in that inside world. Sacks says: The exploration of deeply altered selves and worlds is not one that can be fully made in a consulting room or office. The French neurologist François Lhermitte is especially sensitive to this and, instead of just observing his patients in the clinic, he makes a point of visiting them at home, taking them to restaurants or theatres, or for rides in his car, sharing theirs lives as much as possible. [.] With this in mind, I have taken off my white coat, deserted, by and large, the hospitals where I have spent the last twenty-five years, to explore my subjects’ lives as they live in the real world, feeling in part like a naturalist, examining rare forms of life; in part like an anthropologist, a neuroanthropologist, in the field –but most of all like a physician, called here and there to make house calls, house calls at the far borders of human experience. (Ibid., pp. xix-x) Our clinical reports are home visits of a special relationship, the therapeutic relationship. In this space we explore the way in which these persons have built up their inside worlds and organised a way of being, a character, that allow them to face their biological and environmental circumstances. And how do they do it? Regulating through their breath and their motor system the amount of energy that they can deal with so that their instinctive demands are adapted to the environmental demands, that is to say to the demands of the relationship with others, it is precisely our field of work and study. The personality of each human being is the result of that adaptive and functional regulation. Each one of us is a being biologically determined by some genes, a body, a sex, that has to learn how to modulate its impulses, to adapt itself to the demands and limitations that its environment imposes. Since the acquisition of the temporal sequences, the sphincter control and all the motor system, the learning of space, etc. the formation of personality is a constant interaction between the biological part and the environmental part. Now we will speak about the Tourette Syndrome, this missing chain between body and mind, that is put precisely in this field in which the biological part and the environmental part don’t get conjugated, in which the conflict between impulse and symbolization bursts out, it resolves in favour of impulse under determined conditions and it pushes off and supplants the ego in such way that the unconscious becomes a performance, overcoming the barriers of the ego. From our Bioenergetic model, we would describe this situation as an energy level further over the ego capacity, the contention and orientation psychical system. In psychoanalysis is spoken about acting out, passing by to the act. We all refer to this as impulsiveness, and we diagnose it as mania when we find a person that is in a state of great excitement and hyperactivity that impedes the regulation of its impulses and in consequence its behaviour. There we see a failure, a defection or limitation of the ego in the fulfilment of one of its functions, that one of the modulation of the impulses, and we look for the origins of this so usual failure in the border-line organizations and in the manic-depressive psychosis. Lets see how the neurologists describe this situation of energetic overflowing from the point of view o the “nervous essentials/basis//foundations of the ego” Sacks tells the story of Ray, a man that goes to his consulting room when he is 24 because he was almost disabled due to his multiple tics of extreme violence that were produced in bouts every few seconds. He had them since he was 4 and he suffered for the way in he drew the attention of others and the reactions they provoked. These were involuntary exclamations of insults (fuck you, shit), impatience expressions, fits of belligerence or cheeky and impertinent interventions that logically disturbed his relationships in daily life. Despite this, his great intelligence, his wit, his strength of character and his sense of reality allowed him to study in school and in the university, to have a few friends and get married, although his marriage was threatened by his exclamations and uncontrollable insults when his sexual excitement increased. His success in studies did not continue in his working life. He was fired from a dozen jobs, not for incompetence but due to hid bursts that impeded him to maintain the composure required by the social norms. What allowed him to survive, economically and emotionally was his extraordinary talent as a jazz drummer. When he played the drums, the tic turned into the core of a marvellous and unstoppable extemporization, in such a way that the “intrusive impulse” became an advantage. It was also an advantage in certain games. Specially in ping-pong as, due to an abnormal speed of reflexes and reactions, he threw unexpected, sudden, nervous, unforeseeable shots to the rival. He was only free of tics in the post-coitus relax or during sleep. Also when he swam, sang or worked rhythmically and regularly and found a “kinetic melody”, a rhythm in which he was free of tension. With this symptoms, Sacks establishes a diagnosis of Tourette Syndrome for this patient. What is this syndrome? In 1885 Gilles de la Tourette, a pupil of Charcot, described the astonishing syndrome which now bears his name. 'Tourette's syndrome', as it was immediately dubbed, is characterised by an excess of nervous energy, and a great production and extravagance of strange motions and notions: tics, jerks, mannerisms, grimaces, noises, curses, involuntary imitations and compulsions of all sorts, with an odd elfin humour and a tendency to antic and outlandish kinds of play. In its 'highest' forms, Tourette's syndrome involves every aspect of the affective, the instinctual and the imaginative life; in its 'lower', and perhaps commoner, forms, there may be little more than abnormal movements and impulsivity, though even here there is an element of strangeness. It was well recognized and extensively reported in the closing years of the last century. It was clear to Tourette, and his peers, that this syndrome was a sort of possession by primitive impulses and urges: but also that it was a possession with an organic basis - a very definite (if undiscovered) neurological disorder. (1987, p. 92) What has been discovered in these last years is a clear confirmation of what Gilles de la Tourette had already guessed: that the syndrome has really a neurological organic basis and is a disorder of those primitive parts of the brain that govern the “march” and the direction. It is a disorder of the instinctive and main bases of behaviour, and the alteration seems to be situated in the highest part of the “old brain”: the thalamus, the hypothalamus, the SISTEMA LÍMBICO and the tonsil that are where the basic, affective and instinctive determinants of the personality are situated. The same happens to some patients with certain encephalitis, patients with the Tourette Syndrome, due to any cause (attacks, brain tumours, poisonings of infections) it seems that they have an excess of exciting neurotransmitters, above all of the dopamine neurotransmitter in their brain. On the other hand, in the brain of a victim of Tourette Syndrome there is not only an excess of dopamine, as well as there is not only a deficiency of it in the brain of a patient with Parkinson disease. There are also mucho more subtle and much more general changes, as it should have been supposed being a disorder that can alter the personality: there are innumerable and subtle ways of abnormality that differ from one patient to another and from day to day in each patient. Haldol, one of the medicines used to reduce the action of the dopamine, can be a solution for the Tourette Syndrome, but nor this one nor any other drug can be the solution for the Parkinson disease. Any purely medical approach, or physician, must also have as a complement an “existential” approach. Lets see what happened, once diagnosed Sacks prescribed Haldol to this patient and he gave him an appointment for the next week. He went back with a black eye and a broken nose. The medicine was a failure. The patient told him literally “So much for your fucking Haldol!”. What happened: the drug had altered his speed, his rhythms and rapid reflexes. And with this the movements coordination. As a result of this he broke his nose with a revolving door. The tics had not disappeared but they were slower and more long lasting and he passed from hyperactivity to catatonia and psychomotor blocking. But the fundamental problem was even another one, it was really an identity problem. Lets listen to the patient: “Let suppose that you could take away my tics. What would be left? I’m made of tics… there is nothing more” (ibid., p. 98). That is to say that the basic identity of this patient, what he was, the way he recognised himself, could not be separated from his tics. He “was” like that. He couldn’t imagine himself without that integrating part of his being. Of his sensation of himself. He called himself “Mr. Ingenious tic” and he even wasn’t sure that he wanted to be different. To treat this matter, Sacks decided to do a psychotherapy and fixed a weekly appointment with this patient, dedicated to imagine life without Tourettism and during this time he was given no medicines. Despite of the strong resistance to changes, they got to rescue and infer the non tourettic identity islands from Ray’s personality. Ray ignored how was what we call normal life. Sacks says that he was overwhelmingly dependant on his exotic illness. Due to this the administration of the drug supposed an unbearable experience for the patient. He changed suddenly his psychomotor experience, as he modified his energy level, and from there, the steps from hyperactivity to catatonia. Thoughts and sensations flowed at an unknown rhythm, too slow, also modifying his perception. At the same time his place before others, the place of the funny man, the clown or the musical genius, what we could call character or usual way of behaviour and relationship, disappeared suddenly without letting him know how to be, who to be, how to situate himself. Without being prepared for this other experience of himself. After months of psychotherapy intended to prepare Ray for the experience, Sacks prescribed the medicine once more and he describes the follow up during the next nine years. I mention his report extensively: During his working hours, and working week, Ray remains “sober, solid, square” on Haldol -his is how he describes his “Haldol self.” He is slow and deliberate in his movements and judgments, with none of the impatience, the impetuosity, he showed before Haldol, but equally, none of the wild improvisations and inspirations. Even his dreams are different in quality: “straight wish-fulfilment,” he says, “with none of the elaborations, the extravaganzas, of Tourette's.” He is less sharp, less quick in repartee, no longer bubbling with witty tics or ticcy wit. He no longer enjoys or excels at ping-pong or other games; he no longer feels “that urgent killer instinct, the instinct to win, to beat the other man”; he is less competitive, then, and also less playful; and he has lost the impulse, or the knack, of sudden frivolous moves which take everyone by surprise. He has lost his obscenities, his coarse chutzpah, his spunk. (Ibid., p. 100) But the most important and incapacitating thing for Ray, as this was fatal for him is that he has
discovered that with the medicine he was musically “dull”, ordinary, competent but with no
energy, with no enthusiasm and joy. He didn’t have tics and didn’t hammer away the drums
compulsively… but he didn’t have any more overwhelming and creative outbursts.
When this standard became patently clear and after analysing it with Sacks, Ray took a
transcendental decision: he would take Haldol “compulsorily” during the working week, but
would do without it and would “outburst” during weekends.
And now there are two Rays, one with Haldol and another one without it. There is a sober, deep
thinking, deliberate citizen from Monday to Friday; and there is the “Ray Mr. Ingenious tic”,
frivolous, frenzied, inspired during weekends. It is a strange situation, and Ray is the first one
that admits it saying:
Having Tourette's is wild, like being drunk all the while. Being on Haldol is dull, makes one square and
sober, and neither state is really free. You normals, who have the right transmitters in the right places at
the right times in your brains, have all feelings, all styles, available all the time - gravity, levity, whatever
is appropriate. We Touretters don't: we are forced into levity by our Tourette's and forced into gravity
when we take Haldol. You are free, you have a natural balance: we must make the best of an artificial
balance. (ibid., p. 101)
What Ray evidently says here is that both egos, due to their lack of integration are clearly
unconnected with him, Ray is not the owner of his seriousness or his frivolity. It is not in his
hands to pass from one position to the other. It depends completely on an outside fact: Haldol
yes, or Haldol no; Tourette yes, our Tourette no, that sets him up on one way or the other.
But his view with respect to “normal people” is excessively optimistic. What would our
masochist patients say that they feel prisoners in a character armour that turns them serious,
phlegmatic and formal. We could call it a Haldol character armour if you allow me this
extrapolation.
Why?
Of we analyse the function of the medicine, we observe that it acts as an auxiliary ego to
compensate a lack of the energetic contention and modulation and also to compensate an
insufficiency in the repression mechanism. Repression of contents and management of the
impulse energy so that they don’t reach the motor system, they are defined as defensive
character functions. It’s easy to imagine Ray Haldol as a patient that arrives at our consulting
room complaining about a lack of motivation, compression sensation or angst, a sensation of
being fed up, etc. A minimum exploration would work out to an excess of control and if we
sounded out the associated fantasies to the idea of lack of control, what would we find there?,
who would we find there? Ray Mr tic of weekends.
To conclude lets try to take out some teachings from this case:
1st It allows us seeing that what Freud called synthetic function of the ego, that is to say the
capacity to coordinate and integrate the mental part with emotion and movement, depends on
that the amount of impulse energy does not exceed precisely this ego capacity. If there is an
excess of energy it goes to the motor system and the action without being possible to be
coordinated by the ego and it appears as a tic or actuation.
In this sense, the bioenergetic approach of taking into account in the therapy, the quantitative
aspects of the quantities of energy and contribute to its regulation, goes towards making easier
the integrating labour of the ego.
2nd That this labour seems to be made easier as long as rhythmic guidelines are established as in
music or in games, creating what Sacks calls a kinetic melody as in the exercises we did
yesterday at Alcina’s or Jaime’s workshops. Or break the guideline when suggesting the release
with classic bioenergetic exercises, when the guideline becomes a prison for the impulse,
facilitating this way, the creation of a more flexible guideline.
3rd That the emotional quality depends absolutely on the excitement levels. As Ray says, the
more excitement, more joy and creativity, more colour and creativity and also more risk of loss
of integration. At the same time with less excitement everything is more grey, phlegmatic,
boring and lacking in motivations.
4th That as Reich indicated about the function of orgasm, sexuality is a privileged source of
release and so a privileged producer of integration. In fact you will remember that the
spontaneous disappearance of tics was only produced in the post coital relax.
Gathering other cases that Sacks presents we would continue drawing useful conclusions for our
comprehension that support and explain our practice. The same thing happens with all the
present investigation about brain functioning that goes precisely towards the integration of the
biological and the psychological matters. I thank Sacks because for the moment he has helped
me to know that in bioenergetic we are on the right way and this is what I wanted to share with
you.
Bibliography

Sacks, Oliver (1987): The Man Who Mistook His Wife for a Hat, and Other Clinical Tales. New
York: Harper and Row.
(1996): An Anthropologist on Mars. Vintage.

Source: http://www.bioenergetica.es/docs/Traducci%C3%B3n%20articulo%20-%20Sndrome%20Tourette.pdf