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(2003).

International Journal of Psycho-Analysis 84: 1079-1084

La pense clinique

Clinical thinking Andr Green. Paris: Odile Jacob, 2002. pp. 359.
Review by

Dominique Bourdin1
Green's thesis is that there is a form of clinical thinking that stimulates patients to remember while fulfilling all the
requirements of rigour that pertain to any other form of thinking. Following his Introduction, specially written for this book, in
which he defines and characterises the concept of clinical thinking and its requirements, Green draws together various articles that
illustrate how this thinking can be implemented.
The term clinical thinking contains a creative paradox that acknowledges the workings of a genuine form of thinking in
psychoanalytic clinical practice which most closely resembles the analysand's experience and is inseparable from the treatment
experience. This is an original and

1 Translated by Sophie Leighton, MA (Oxon), MA (Sussex).


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specific mode of rationality that arises from practical experience. Clinical thinking encompasses the transformations imposed by
anguish, suffering and pain and the strategies used to deny or counteract them in an attempt to get rid of and sometimes go
beyond them. The analysand is thus concealed within the lines of this writing despite being absent from the explicit discourse.
Clinical thinking forges the concepts that give a voice to the reasons of the unconscious and the diversity of the responses and
transformations to which its activity gives rise.
Psychoanalytic treatment also refers to the person whose task it is to listen to the suffering with a particular sensibilitythe
analyst: it therefore necessarily involves the questions connected with the transference and countertransference. A work of
thinking takes place in the psychoanalytic encounter, and this internal representationa subterranean form of work that proceeds
in silencerequires acknowledgement by other psychoanalysts, especially by those who are unfamiliar with the initial context in
which this thinking emerges. It is this that makes the role of writing so essential. There will certainly always be an unbridgeable
gap between theory and practice. This hiatus and the part played by uncertainty are irreducible in psychoanalysis: the psyche can
only be approached obliquely; it communicates through the signs it makes.
Following this outline of the concept of clinical thinkingwhich originated with Freud's account of the Dora casethe
author uses his Introduction to trace the historical background, starting with Freud's delimitation of the field of psychoanalysis,
then confined to the psychoneuroses, and subsequently taking in both Klein's and Ferenczi's reinterpretations, and the multiple
extensions and revisions of contemporary post-Freudian psychoanalysis.
Clinical thinking establishes links, the work of the negative, latency and a capacity for interpretation, and the workings of
affects that are nevertheless held in check. However, at present there is a risk of the fundamental references being dispersed; in
the face of this extreme complexity, the old Hollywood-style oversimplificationsa regression to simple ideas, practical solutions
and easy formulasare proving tempting. We therefore have to acknowledge, despite the remarkable achievements of Freud's
posterity, that there is a crisis in psychoanalytic understanding.
Following this study of the concept of clinical thinking, a path is proposed that is at once divergent and coherent. As an
intersection point of fundamental problems, the articulation between the intrapsychic and intersubjective dimensions explains the
post-Freudian transformation. However, the consideration of borderline cases (or, to use a better term, non-neurotic structures),
the question of the relationships between representation and affect and the critique of drive theory are increasingly casting doubt
on this articulation.
The axis of treatment is directed towards illuminating the intrapsychic dimensionthe analysand's internal worldbut the
transference forces the analyst to enter into the game, since he is involved in the psychoanalytic process through the projections of
which he is the object. The analysis of these projections and the response he gives to them, which involves the effective
participation of his own psychic reality, then reflect the patient's psychic reality. From the intrapsychic dimension emerges the
central hypothesis of the drive; from the intersubjective dimension appears the perspective inaugurated by the object relationship.
The object thus finds itself in a dual position, belonging both to internal space (conscious and unconscious) and to external space,
as another subject.

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A multiplicity of content thus corresponds to the psychoanalytic concept of the object: the object as target of the search for
drive satisfaction; the real object and the fantasy object; the oedipal object of the difference between sexes and generations;
Klein's internal object; Winnicott's transitional object The object is complex and contingent from the viewpoint of the drive,
unique and irreplaceable, however, for the melancholic; for Lacan it is partial, provided that it puts forward the notion of the
Other. The object is what reveals the drive: it is the object
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that manifests it. But the object is inhabited by its own drives. There is no unified conception of the object; there is therefore
always more than one object, contrary to the assumption inherent in the genetic solution that focuses exclusively on the primary
object.
Against this line of descent for the object, the author formulates a line of descent for the subject. For the new metapsychology
is centred on the study of relations between Self and object. The inadequacy of the concept of the ego leads to discussion of the
subject, the I, the person and finally the Self (with its various meanings). It is the dynamics between the object and subject
lineages that matter here, but the attention paid to them should not involve an idealisation that sacrifices the Freudian drive.
A review of the relationships between perception and representation reminds us of their complexity, which is progressively
demonstrated here, allowing for the existence and function of negative hallucination to be underlined. Neither sensoriality nor
reality-testing suffice to explain perception, whereas the representational field is extended by it; the idea of the psychic
representative of the drive is shown to correspond to a gradient upon which the force, crossing psychic spaces and thereby
transformed, moves from the outlet of the discharge (somatic, hallucinatory or acted out) to the long circuits of revision, which
itself takes multiple forms. Accordingly, psychoanalytic practice increases in scope, to include somatic problems, psychoses and
psychopathies.
If the intrapsychic and intersubjective dimensions are opposed, they must be articulatedonly inside, also outside, as Csar
and Sara Botella express it (2001). The concept of psychic work is essential for understanding the drive not as something
originating from the raw psyche but as the centre and the product of work; this elementary psyche can now be understood also in
terms of an intrapsychic grid based on the excitation originating from the child's state in his relationship with the mother. The
primary matrix from which the later differentiations emerge is both intrasubjective and intersubjective. Thus, the driveobject
equilibrium has been broken in the course of psychoanalytic history by an accentuation of the role of the object, which was, in
fact, underestimated by Freud, whose fundamental discovery concerned determinism in relation to excitation and thus in relation
to drive activity, the constancy of these factors leading him to emphasise the role of regularityaccordingly of structural as
opposed to accidental factorsin a concern to reconnect the psyche with living processes.
All this suggests that Freudian theory needs to be revised in order to incorporate the role of the object: the object's future
response to the demand contributes to the primitive organising structuring (even if the recognition of the parent's madness can
also be a factor in failure of self-recognition). The drive is the internal source that leads towards object-cathexis and becomes
psychically active on this journey from the source to the goal (Freud, 1933). The psyche is activated in proximity to the object,
which gives rise to the relationship between an elementary psyche, threatened with disorganisation, and a developed psyche that
responds to this demand according to the nature of the psyche. The mother's desire for the child to be satisfied responds to the
child's desire for satisfaction. Furthermore, the satisfaction produces the incorporation of what the object provides and, as a result,
of the object itself; hence the dual position of the incorporated object, that is both internal and external, in an irreplaceable
paradox. The pleasure of satisfaction thus has a retroactive value of creation, for it allows subjective appropriation to occur. It is
therefore from the pair constituted by the drive and the object, or by the child and the mother, that the development of the psyche
proceeds, in a tension between the demand and the imperfect nature of the responses, which opens the way to the destiny of the
drives and the need for defences.
The object remains in essence unknown and polysemous, arousing desire while remaining inaccessible. Freudian theory must
be revised on the basis of the analytic exchange: in the
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treatment the path of self-examination includes a detour via the other. In the analytic situation, contact with the object is
impossible and forbidden; it shies away just as it reveals; it offers itself to the transference without replying, except by
interpretation, to the demands for satisfaction. But this acknowledgement is partly equivalent to satisfaction, for it allows psychic
change to take place: the object is projected, represented and constructed, whereas the drive is dynamic, self-organising and
subject to transformation. The construction of the object leads retroactively to the construction of the drive that constructs the
object in a dialectical impulse: the cathexis of the object constructs it as an object, whereas its proximity and then its
incorporation construct the drive retroactively, giving form to the inaugural expression of the subject.
The analysing situation cannot therefore be described solely in terms of a discourse that expresses the transference and the
resistance to the analyst's silence, broken at the appropriate moment by an interpretation. For there is an unmistakable dual aspect

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to the transference: there is both a transference to the wordsfor everything has to be formulated in themand a transference to
the analyst, which gives rise to the intersubjective relationship. The words addressed to another person in the course of the session
are based on an interplay of established excitations. Excited by the exercise of the fundamental rule, the unconscious pushes
towards an expression that itself provokes an unconscious excitation, in relation to the drive source that in turn recathects and
enriches the circuit of the words. Even if certain analysands say that they cannot speakbeyond the action of the censor, the
representational network is thereby cut, whether in terms of a thought as something inseparable from the body and acting out, or
in terms of a hallucinatory diversion of thoughtsthey are confronted with the unthinkable.
Speech engenders meaning addressed to the other who is the intended listener. The intrapsychic and intersubjective
dimensions echo each other. Further, the reference to the intrapsychic concerns the effects of biological organisations, whereas
the intersubjective recalls the effects of the social environment. However, the intrapsychic dimension requires the detour via the
intersubjective, whereas the other of the intersubjective dimension is involved in its own constitutionhence the biological
reference. The radicalism of Freud's drive theory is manifest in the move to the second topography, which removes all reference
to consciousness, even in negative terms. The new model must account for the propensity to act out, and it therefore no longer
falls within the representational field. Drive theory requires a consideration of the somatic basis of fantasy; it does not simply
allow the representation of a primitive psyche depending on needs of somatic origin but forms the theoretical support to argue for
the idea of a psyche constituted of forces, susceptible to development but to some extent irreducible. The psyche cannot be
described without recourse to the notion of forcethat is, to a dynamic conception of psychic events, essential to Freudian
thought. Binding is the inaugural form of meaning. Nothing can be constructed without this alloy of force and meaning created
through the mediation of the representative. This does not mean that the metabiology that we need should be taken literally: it is
primarily the unthinkable part of the metapsychology.
Three studies are then presented to demonstrate the relations between neuroses and non-neurotic structures.
First, a differential study brings together and compares hysteria and borderline states; this chiasmus is shown to give rise to a
definite displacement, which also explains neurosis in terms of borderline states, instead of thinking of non-neurotic structures in
terms of neurosis, as is more usual. The consideration of the phenomena of thought and of the notion of force in psychic
functioning gains new impetus from this study.
Second, primary anality, an important concept for understanding non-neurotic structures, is considered in the context of the
entire anal relation and of the continuation of the work of Karl
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Abraham. It is described in terms of the way in which the analysis of borderline states is hindered by the omnipotence
projectively attributed to the analyst, which leads the analysand to struggle against the transference and to deny any power to the
transference object (which is nevertheless by definition fallible and limited). The fixation with primary anality corresponds to an
injured narcissism, indicated by a severely scarred wound.
An unconscious erotisation of conflicts ensues: opposition is vital for the delimitation of identity. There is no persecution
here as such, but instead the conviction of not being made for reality as it is. Each occasion of conflict repeats the trauma of the
devaluing parental judgement. Thought is experienced as an inalienable possession; as a deployment of the primitive anal object,
it involves a fierce defence of the subjective territory, stemming from a permanent sense of encroachment by others. As regards
the object, a will not to choose is affirmed, to have both the thing and its opposite; hatred seals a pact of eternal fidelity to the
primary object, but the relationship with external objects remains fragile, and the rupture again dooms the subject to solitude with
only its internal objects. In this unconscious negativism, it is more important to say no to the object than yes to oneself, an
attitude that can coexist with recesses of the psyche in which a fusional regression persists: the subject is in secret communication
with a completely good internal object that enables it to escape from objects that always bring disappointment. Even if sexual
desire is judged to be bestial, sexuality becomes easily liberated when love is shared, but the object is problematic as a love
object; renunciation or asceticism are more easily accepted than the risk of decathexis by the object. The denial of the self-image
can go as far as negative hallucination in the mirror, where the subject defines itself only through the image that others send back
to him of himself.
Primary anality corresponds to the sense of the end of symbiotic omnipotence; the difference has been established, forcing
the subject to confront incomprehension, non-coinciding desires and the object's inconstancy. The subject does not acknowledge
the other's right to be different and feels in return the distress at not being recognised himself. The analyst's countertransference,
through feeling, provides a mirror-like reflection of the subject's problematic, and relentlessly makes perceptible the
ineffectiveness of a relation the interruption of which would nevertheless constitute an insurmountable trauma for the patient. It is
therefore simply a question of holding and of resisting the patient's destructive and self-destructive attacks.
This is a long way from neurosis, in a narcissistic character structure that is both rigid and fragile. Sometimes the narcissism
cracks into a despair and a disappointment that are much more radical than those of hysteria; the impotent rage and anger
remobilise the subject but leave it in pieces. A manic vision of the world becomes established, which is constituted without
mania by a disconcerting form of thinking that is paradoxical, if not cunning, but astonishing in its dialectical inventiveness.

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Negativism, obstinacy, need for domination and parsimony in libidinal exchanges all justify the reference to anality.
Finally, a chapter is devoted to the central phobic position, to a description of the avoidance mechanisms at work in a session,
which are explained by the idea of an anticipated actionan anticipation of the psyche that has a presentiment as to where the
associations will lead it, well in advance of their thought or expression. The death drive, considered as a destructive force, is also
revisited and reinterpreted, as are the (non-)differentiation of affect and representation, and thirdness.
The book's final chapter illustrates the crisis in psychoanalytic understanding and the possible ways of resolving it, inviting
us to distinguish between the work of psychoanalysis, conducted in the analyst's consulting room (including also psycho
therapies), the work of the psychoanalyst, carried out beyond this setting (hospitals, clinics, universities etc.) and the work of the
psychoanalysed.
The book as a whole provides an exciting demonstration of the results, already well
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elaborated, of the revision of Freudian thought to which Green has contributed, with the concern to remain as close as possible to
the treatment, and to integrate post-Freudian developments without renouncing any of the Freudian revisions but also without
making them sacrosanct. We need to reinterpret them in their fundamental intuitions, while still giving an account of their limits,
and also enriching them clinically and theoretically. We are definitively post-Freud, while also remaining with him to examine
our knowledge.

References
Botella C, Botella S (2001). La figurabilit psychique. Paris/Lausanne: Delachaux et Niestl, 2001.
Freud S (1933). New introductory lectures on psycho-analysis S.E. 22.[]
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Article Citation [Who Cited This?]


Bourdin, D. (2003). La pense clinique: Clinical thinking Andr Green. Paris: Odile Jacob, 2002. pp. 359. International Journal
of Psycho-Analysis 84: 1079-1084

WARNING! This text is printed for the personal use of the owner of the PEP Archive CD and is copyright to the Journal in
which it originally appeared. It is illegal to copy, distribute or circulate it in any form whatsoever.