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THE CONTINUUM BETWEEN NORMAL AND PATHOLOGICAL IN

PSYCHOPATHOLOGY
Freud, Canguilhem and Neurosciences

Jessica Tran The, Translator Kirsten Ellerby


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Association Recherches en psychanalyse | « Research in Psychoanalysis »

2018/2 N° 26 | pages 154 à 163


ISSN 1767-5448
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Res. in Psychoanal. 26│2018
Research in Psychoanalysis 26│2018/2
Feature Section “Psychoanalysis, Genetics and Neurobiology”

The Continuum between Normal and Pathological in


Psychopathology
Freud, Canguilhem and Neurosciences
Le continuum entre normal et pathologique en psychopathologie
Freud, Canguilhem et les neurosciences
[Online] Dec. 28, 2018

Jessica Tran The


Abstract:
In his essay on The Normal and the Pathological (Canguilhem, 1991), Canguilhem undertook to make a fervent critique of Broussais’
principle according to which, a pathological state would be a modification in the normal state that could be understood in purely
quantitative terms. Canguilhem’s theorisation of a qualitative approach to the individual who is in a state of morbidity, although not
referring specifically to psychoanalysis, is nevertheless rich in possible links to Freudian psychopathology.
In this article we will begin by questioning the meta-psychology of the normal and the pathological, from the stand point of
the problematic of a possible continuum, reduced to a purely quantitative understanding, of the pathological processes. We
will then go on to study what changes recent discoveries in neurosciences have introduced to the problematic of the
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qualitative and the quantitative in psychopathology. Although advances in genetics and neurobiology have linked a
dysregulation of the dopamine system to schizophrenia, thus reintroducing a quantitative measure where for Canguilhem
there was no measurable and objective criteria for psychopathology, we propose investigating how research on neuronal
plasticity – in the wake of by the Nobel prize for medicine given to Eric Kandel – makes it possible to reintroduce the
problematic of the qualitative into these considerations.

Résumé:
Georges Canguilhem, dans son essai sur Le normal et le pathologique, s’était livré à une fervente critique du principe de
Broussais selon lequel le pathologique reviendrait à une modification concevable en termes purement quantitatifs de l’état
normal. Sa théorisation d’une approche qualitative de l’être-malade, bien que dépourvue de référence explicite à la
psychanalyse, est néanmoins riche de liens possibles avec la psychopathologie freudienne.
Après avoir tenté d’interroger la métapsychologie du normal et du pathologique relativement à la problématique d’un
continuum possible qui ne se réduise pas à une appréhension uniquement quantitative des processus psychopathologiques,
nous étudierons quels remaniements les découvertes récentes des neurosciences ont induits au sujet de la problématique du
qualitatif et du quantitatif en psychopathologie. Si les avancées de la génétique et de la neurobiologie ont pu mettre en avant
une dérégulation du système dopaminergique dans la schizophrénie, réintroduisant ainsi une mesure quantitative là où, pour
Canguilhem, la psychopathologie était dépourvue de tout critère mesurable et objectif, nous pourrons étudier comment les
travaux sur la plasticité neuronale ouverts par le prix Nobel de médecine Eric Kandel permettent de réintroduire une
problématique d’ordre qualitative dans ces perspectives.

Keywords: Canguilhem, Freud, normal, pathological, neuroscience


Mots-clés: Canguilhem, Freud, normal, pathologique, neurosciences

Plan:
Introduction
A Freudian Meta-Psychology of the Normal and the Pathological?
Neurosis, Psychosis, and Normality in Freud’s Writings
Neurosis and Psychosis in the Teaching of Lacan: an Opposition between Structures?
Contemporary Neurosciences: the Return of a Quantitative Psychopathology?
A Renewed Clinical Practice
Conclusion

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The author:
Jessica Tran The
Clinical Psychologist at Établissement Public de Santé Érasme and Centre Médico-Psychologique. PhD Candidate in
Psychoanalysis and Psychopathologie at Department of Psychoanalytical Studies, Paris Diderot at Sorbonne Paris Cité
University, IHSS, Lab. CRPMS.
Université Paris Diderot, Sorbonne Paris Cité
Campus Paris Rive Gauche
Bâtiment Olympe de Gouges
11, rue Jean Antoine de Baïf
75013 Paris
France

Electronic Reference:
Jessica Tran The, “The Continuum between Normal and Pathological in Psychopathology, Freud, Canguilhem and
Neurosciences”, Research in Psychoanalysis [Online], 26|2018/2 published Dec. 28, 2018.
This article is a translation of Le continuum entre normal et pathologique en psychopathologie, Freud, Canguilhem et les
neurosciences. (Translator: Kirsten Ellerby.)
Full text

Copyright
All rights reserved
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Conflict of Interest Statement
Jessica Tran The declares that the research was conducted in the absence of any commercial or financial relationships that
could be construed as a potential conflict of interest.

Introduction
In the first part of his 1943 thesis, George Canguilhem argued against a purely quantitative view of the
distinction between normal and pathological. His study opened with this question: ‟Is the pathological
state merely a quantitative modification of the normal state?” (Canguilhem, 1991, p. 37). The
formulation of this problematic originated in a strong critique of Broussais’ principle, a principle that
dominated the positivism of Comte, and the experimental psychology of Claude Bernard. Indeed, if
according to Broussais diseases were ‟the excess or lack of excitation in the various tissues above or
below the degree established as the norm.” (Canguilhem, 1991, p. 48), August Comte would attribute a
universal scope to this principle, proclaiming a sameness between pathological phenomena, and normal
phenomena ‟from which they differed only in terms of intensity” (Canguilhem, 1991, p. 49), insofar as
these phenomena had the same structure.
Thus this thesis goes beyond the proclamation of a simple continuity, since it affirms there is a
relationship of sameness between the normal and the pathological. Canguilhem interprets this as a
negation of the qualitative difference accepted by the Vitalists. In an explicit reference to Hegel’s
Science of Logic (Hegel, 1812), he makes the formula, according to which quantity would be quality
negated, his own. Thus, the negation of a qualitative difference would necessarily lead to the
affirmation of a homogeneity that could be quantitatively expressed. Through this critique of the
quantitative understanding of pathological phenomena, Canguilhem develops a qualitative approach to
the individual in a state of illness; de-centring the objective judgement of the doctor as regards
pathology, towards that of a subjective appreciation made by the patient himself of his new state of
being. Illness is thus understood as the introduction of a new norm, created by the living being, in
response to a change in its environment.

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Canguilhem states at the start of his work that psychopathology is not the central object of his
reflection, he refers in his introduction to a holistic approach to pathological phenomena, taken as part
of the question of the living being as a whole, where ‟A congenital clubfoot, a sexual inversion, a
diabetic, a schizophrenic,…” (Canguilhem, 1991, p. 33) are all equally part of the same problematic. It
could prove instructive however, to extrapolate the epistemological pairing made up of the opposition
between a quantitative concept and a qualitative concept of the pathological with the specificities of
psychopathology, both from a psychoanalytic point of view as from that of the most contemporary of
neurosciences.

A Freudian Meta-Psychology of the Normal and the Pathological?


Freud, with his The Psychopathology of Everyday Life had, as early as 1901, stated the existence of a
continuum between the normal and the pathological psychic processes. He would go so far as to argue
(making his own a statement made by Jung) that healthy individuals ‟...fall ill of the same complexes
against which we healthy people struggle as well.” (Freud, 1908e, p. 210). Similarly, when he was
studying the paranoia of President Schreber, he apologied for the monotony of the solutions offered by
psychoanalysis, always bringing up his famous paternal complex (Freud 1911c). To this proclamation of a
continuity between mental health and pathology is added, in the Freudian elaboration, the unfolding of
the economic model of the psychic processes, with the theory of the pleasure principle, and also with
the homeostatic principle of constancy that will continue into his subsequent theory of the dualism of
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drives. Thus, the psychic apparatus strives towards the discharge of both external and internal
excitations, in order to regain an ideal homeostasis.
We could seek to question the Freudian text retrospectively, in the light of the Canguilhem’s Essay on
Some Problems Concerning the Normal and the Pathological (Canguilhem, 1991); rereading it through
the prism of the dialectic, expressed by Canguilhem, between the quantitative and qualitative concepts
of pathology. Could there be in Freud’s thinking, beyond the resolutely quantitative economic model, a
qualitative distinction between the normal and pathological psychic processes?
In A Project for a Scientific Psychology (Freud, 1895a), the principle of constancy appears to be modelled
on the biological mechanism of homeostasis. The aspect of the psychic apparatus that is termed
economic, is characterised by the idea that the pleasure principle aims for the discharge of the
excitation to restore the lowest quantitative level of psychic excitation. In 1894, in his first article on The
Neuro-Psychoses of Defence (Freud, 1894a), Freud argued that to express his distinction between
hysteric neuroses, obsessional neuroses, and paranoia he had had recourse to ‟an auxiliary
representation”, something that it would be necessary to

[...] distinguish – a quota of affect or sum of excitation – which possesses all the characteristics of a quantity (though
we have no means of measuring it), which is capable of increase, diminution, displacement and discharge, and which is
spread over the memory-traces of ideas somewhat as an electric charge is spread over the surface of a body. (Freud,
1894a, p. 60).

To reread this concept in relation to the work of Canguilhem we could situate this ‟auxiliary
representation” to which Freud turns, as being similar to a dynamic model of medicine in terms of an
equilibrium to be maintained. This is a model that appears to be the philosophical heir to the
Hippocratic theory of humours which, itself, already referred to a homeostatic ideal.
However, alongside this dynamics perspective we find in Freud’s texts references to the symptom as a
‟foreign body” (Freud, 1939a, p. 94), or as ‟a State within State” (Freud, 1939a, p. 76); something
assimilable to what Canguilhem describes as an ontological medicine, based on the model of the
microbe as external agent that would come to act as a parasite on the organism.

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Thus, Freudian thinking cannot be reduced to the opposition between dynamics medicine and
ontological medicine established by Canguilhem; nor to an opposition between quantitative and
qualitative concepts of psychic pathology.
This coexistence of different levels of explanation for the psychic processes could belong to the very
definition of the drive, as a concept at the boundary between the somatic and the psychic; a concept
that is fundamentally double-headed: on the one hand the quantum of affect, pertaining to the
economic model, thus quantitative; and on the other the representation – more specifically the
representative-representation, according to the translation of the The Language of Psychoanalysis
(Laplanch & Pontalis, 1981) – a notion that is resolutely qualitative and non-quantifiable. Indeed, despite
the importance of the economic model throughout Freudian thinking (and he would confide as late as
An Outline of Psycho-Analysis (Freud, 1940a [1938]) having ‟neglected” this economic point of view), the
distinctions formulated by Freud between neurosis, psychosis, and normality are for their part
expressed in qualitative terms, within a dynamics model of the psychic apparatus. Insistence on a
quantitative dimension would not seem to be apparent in Freud’s thinking, not in a way that could be
understood in terms of the Hegelian definition of quantity perceived as negation of quality; because
there is always the addition of a constant reflection on the distinct nature of the mechanisms at play in
the different psychic pathologies.
In 1894, in his first text on the neuro-psychoses of defence, Freud described psychosis as ‟a much more
energetic and successful kind of defence” (Freud, 1894a, p. 58): to the first adjective ‟energetic”, which
is quantitative, is straight off added a qualitative interpretation of the efficacy of the defence. Paranoia,
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defined as a defensive psychosis, would thus, according to this text, stem from the rejection of both the
representation and the affect, the ego behaving ‟as if the idea had never occurred to the ego at all”
(Freud, 1894a, p. 58).
Whilst neurosis would operate through the separation of the representation from its affect (Freud,
1894a). However, in Freudian thinking, the psychopathological categories of neuroses and psychoses,
inherited from psychiatric nosography, are understood as being supple and permeable; thus ‟...it is not
rare for a psychosis of defence episodically to break through the course of a hysterical or mixed
neurosis.” (Freud, 1894a, p. 60). Freud would continue to hold this position until 1923, admitting once
again in The Dissolution of the Oedipus Complex (Freud, 1924d) being confronted with ‟...the borderline
– never a very sharply drawn one – ” (Freud, 1924d, p. 177) between the normal and the pathological.

Neurosis, Psychosis, and Normality in Freud’s Writings


In 1924, within the elaboration of his second topic, Freud formulates in his article Neurosis and
psychosis (Freud, 1924b) a qualitative distinction between different modalities of conflict. What signifies
would not be so much the sum of excitation in play, but rather the fact that neurosis is the result of a
conflict between the Ego and the Id, whilst psychosis is the similar outcome of an equivalent disturbance
in the relationship between the Ego and the external world (Freud, 1924b). In a second text from 1924,
The Loss of Reality in Neurosis and Psychosis (Freud, 1924e), Freud pinpoints a difficulty: in actual fact,
the loss of reality exists just as much in neurosis as in psychosis, rendering it impossible to make an
effective distinction between these two psychic pathologies. At the onset of neurosis, the Ego, working
in the service of reality, represses a drive; subsequently, the failure of the repression results in the
wronged part of the Id finding compensation through the pursuit of a fantasmatic activity. With
Psychosis, in the first instance the Ego is cut off from reality; then an attempt, at the expense of the Id,
to reconstruct the relationship to reality is made (Freud, 1924e). Delusion, as a reconstruction of the
world that had fallen apart at the onset of psychosis, would then appear to be an autoplastic solution in
the face of the collapse of the world as experienced by the psychotic.

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Yet, although from its inception psychoanalysis has had as its object pathologic phenomena, through the
symptom of conversion in hysteric patients. Then despite Freud subsequently progressively striving to
refine his psychoanalytic nosography with successive distinctions under changing denominations (actual
neurosis and defence psychoneurosis at first, then transference neurosis and narcissistic neurosis, and
finally in the 1920s neurosis and psychosis). There does exist in Freud’s work a meta-psychological
definition of normality, concomitant with the heuristic primacy that he attributes to pathologic
phenomena (Assoun, 2006).
Indeed, although the creation of a psychopathology of everyday life seems to bring into question the
term ‟normal” (in so far as even phenomena taken from the banality of everyday life could, in their
structure, make use of mechanisms of condensations and displacement similar to neurotic symptoms),
this discrediting of the notion of normal is far from being a constant in Freudian thinking.
In The Dissolution of the Oedipus Complex (Freud, 1924d), Freud describes an ideal normality that would
consist in a ‟...destruction and an abolition of the complex.” (Freud, 1924d, p. 177); in the same way
that he described the ideal of a finished analysis as a state where the repressed would be resolved, and
the lacunae of memory filled in.
The second text from 1924 on the loss of reality, brings to the meta-psychology of the normal a radically
new point of view, with a very precise definition of normality as being a third route that would borrow
both from neurosis and psychosis:

We call a behaviour ‟normal” or ‟healthy”, if it combines certain features of both reactions – if it disavows the reality
as little as does a neurosis, but if it then exerts itself, as does a psychosis, to effect an alteration of that reality. Of course,
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this expedient, normal, behaviour leads to work being carried out on the external world; it does not stop, as in psychosis,
at effecting internal change. It is no longer autoplastic but alloplastic. (Freud, 1924e, p. 185)

Thus, normality is no longer positioned below neurosis in a scale that ranges from normal to neurosis
and ends at psychosis, but is on the contrary defined by the agency of an external modification,
alloplastic, that would not be satisfied with internal changes as in psychosis. We might underline that
this is a purely qualitative definition of what makes up the meta-psychological mechanism of normality,
devoid of references to any quantitative concept.

Neurosis and Psychosis in the Teaching of Lacan: an Opposition between Structures?


If this concept of normality as a third possible route seems at first glance absent from the teaching of
Lacan, it can nevertheless be noted that his attempt to establish a structural difference between
neurosis and psychosis in the 1950s also rests on a qualitative distinction. It is through reference to
structural linguistics that he puts forwards a combined notion made up of the inscription of the paternal
metaphor and its absence, and the foreclosure of the Name-of-the-Father, which he defines in On a
Question Prior to Any Possible Treatment of Psychosis (Lacan, 1958) as the starting point of psychosis.
This definition comes with no reference to anything of a quantitative nature. The distinction between
neurosis and psychosis appears to reside in this dialectic of the absence-presence, bringing into
opposition the Bejahung, or the primordial assumption of a signifier in the Other, and the Verwerfung.
However, in the face of criticism – particularly expressed by André Green – that he had neglected the
economic model, Lacan completed this structural reading of the distinction between neurosis and
psychosis towards the end of the 1960s, by resorting to Fregelian logic in his formulae of sexual identity.
At first glance we might be tempted to interpret this rewriting of the paternal metaphor, through
reference to phallic jouissance, as a rectification into quantitative terms made to his first formulation. In
neurosis, the assuming of the symbolic castration performs a castration of jouissance, which would
them be located outside the body, in the phallic signifier. This is very clear in the first lesson of the

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Seminar R.S.I., where the phallic jouissance is positioned as being outside the body, in the knot, at the
intersection of the real and the symbolic registers, but not part of the imaginary of the body (Lacan,
1975). On the contrary, in the absence of the inscription of the Name-of-the-Father which marks out the
individual who is not subject to castration as an exception, there is with the psychotic a de-localisation
of jouissance into the body itself. The language that focuses on organs of the schizophrenic, or
hypochondria in paranoia, bears witness to this. However, what we could understand as a quantitative
definition of psychotic jouissance, in so far as it is unlimited and without bounds in the absence of the
limit established by the phallic signifier, hides a distinctly qualitative reality. The statement according to
which psychotic jouissance is more excessive even than phallic jouissance, appears once again as the
consequence of the qualitative distinction between an individual who is subject to symbolic castration,
and another who would avoid it.
Thus, in the wake of Canguilhem, we could understand psychoanalysis as the very possibility which he
imagined: being able to give a definition of the pathological at a psychic level, owing to the
conceptualisation of a qualitative distinction between neurosis and psychosis in psychopathology. Now,
in his thesis Canguilhem resorted to the example of psychopathology to ground his critique of any
quantitative ideal of the pathological, underlining that as it ‟precludes monitoring the relation, which
links a determined disturbance to its supposedly exclusive effect, with sufficient analytical precission.”
(Canguilhem, 1991, p. 50) it allows psychic illness to reveal what remained veiled in somatic medicine:
the primarily qualitative nature of the being-who-is-ill.
Canguilhem thus comes to refer to works, of a phenomenological inclination, by the psychiatrist Eugene
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Minkowski, for whom mental alienation could not be reduced to the veering away from a mean, but
would rather stem from a particular way of being (Canguilhem, 1991). As S. Troubé emphasises,
Canguilhem’s reference to psychiatry inspired by phenomenology tends to underline the definition of
psychic illness as being of the nature of alterity, without explicit connection to an organic cause: ‟it is
this absence, from Canguilhem’s point of view, that allows what was veiled in somatic medicine to be
revealed: the primarily qualitative nature of the being-who-is-ill” (Troublé, 2011, p. 64-79). With its
glaringly obvious inability at the time to define a quantitative norm relative to mental illness, or to
locate it in any specific location of the body, psychopathology serves as a paradigmatic example for
Canguilhem to define the being-who-is-ill as a qualitative entity; an entity that can only be understood
as a whole, as the person who is suffering taken as a singular whole.

Contemporary Neurosciences: the Return of a Quantitative Psychopathology?


These two theses are today undermined by the developments in research in neuroscience in the area of
psychopathology; research where, far from denying any underlying organic causes, ‟objective and
quantifiable”, for psychic pathologies, the trend is rather to strive to detect them. Thus we can observe
the re-emergence of a quantitative idea of these pathologies in contemporary neurosciences, in stark
opposition to the essentially phenomenological psychopathology that was Canguilhem’s reference.
Thus, since the introduction of neuroleptics, neurobiological research into schizophrenia tends to
understand this pathology in terms of a dopaminergeric dysfunction, resulting from overactivity of the
dopamine system, and leading to observable hyperdopaminergia in the acute phases and at the onset of
positive symptoms of schizophrenia. This excessive activity has particularly been confirmed by the use of
neuroleptics, of both first and latest generation, that act through the inhibition of dopamine D2
receptors (Stern, 2014).
Similarly, the neurobiological description of depression tends to consider it in quantitative terms, as an
abnormally low level of serotonin in the nervous system. We could interpret this research as a return to
the principles of Broussais, that is to say to a pre-Canguilhem psychopathology, where mental

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psychopathology stemmed from ‟...the excess or lack of excitation in the various tissues above or below
the degree established as the norm.” (Canguilhem, 1991, p. 47-48). Where we could question the causal
or caused nature of this dysfunction in the homeostasis of the relevant neurotransmitters, is in relation
to other areas of research. For example that undertaken by scientists at Harvard University and MIT
recently published in the journal Nature. This research looks at a genetic aetiology, in so far as a
correlation has been found between a variation of the C4 gene and a reduction in the observable
number of synapses in the brain of schizophrenic patients (McCaroll et al., 2016).
In any event, this research into genetic aetiology could, from the epistemological point of view, lean
towards a return to a structural distinction between the normal and the pathological at the psychic
level. This is a distinction where schizophrenia, beyond the quantitative aspect of the excess of
dopamine, can be understood as an ‟error”, to use Canguilhem’s terminology, a distinction in the
genetic structure itself, that would be qualitatively different in the psychotic subject (and it would be
this genetic difference that would result in an excessive activity of the dopamine system, or the
reduction in the number of synapses).
However, this objectifying way of conceptualising can have as its correlate a ‟closed” determinism, such
as was described by Laplace, and to which Canguilhem refers in his critique of the reduction of quality to
quantity in the equating of the physiological with the pathological (Canguilhem, 1991). This bears
similarities to the way the concept of structure came to be perceived in the 1950s.
The studies mentioned above were strongly controversial in so far as they highlighted not just one gene
but several, and their correlation with the manifest development of schizophrenia remained only 1.25 %
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(Leo, 2016). Furthermore, progress made in epigenetics, and the work that has come in the wake of the
Nobel Prize for medicine on neuronal plasticity given to Eric Kandel, lean more towards an overthrowing
of this determinism, be it genetic, environmental or psychogenic. Thus, beyond the question of a
possible continuity between the normal and the pathological in psychopathology (a continuity that
should not however be seen as identicalness or homogeneity), a new question takes form: that of the
continuity and the discontinuity between determinisms (whatever their origins), and the possible
answer of the subject.
The experimental discoveries that Kandel made with Aplysia, which made it possible to verify Ramon y
Caja’s intuition according to which experience leaves a trace in the nervous system, opened up a whole
new field of research. With the explanation of the mechanism of synapses that allows for this inscription
of experience (Kandel, 2005), these discoveries also opened up the possibility of going beyond the
contemporary neuroscientific paradigm that sketched out a return to the purely quantitative
psychopathology that Canguilhem had specially denounced.
As the work on neuronal plasticity done by François Ansermet and Pierre Magistretti highlighted
(Ansermet & Magistretti, 2007), although experience leaves a trace in the nervous system, there exist
synaptic mechanisms of reconsolidation and deconsolidation through which the traces re-associate. From
this re-association of traces results a paradox that means that the inscription of the experience also
separates from the experience (Ansermet & Magistretti, 2008). This opens up the way for the emergence
of the unpredictable and the unique in a temporal and diachronic process in the advent of the subject.
By creating a shift away from the dialectic of the normal and the pathological, and placing the emphasis
on subjective response, this takes us beyond a paradigm of determinist continuity in the advent of the
subject. This new paradigm rejoins Canguilhem’s idea of illness as the establishing of a new norm
between the living and its environment. Thence, the question would no longer be, as Canguilhem
pointed out, that of the Normal and the Pathological as two abstract entities, but rather of the subject’s
process of becoming within a diachronic logic; where the being who is ill cannot be understood
independently of the subject who defines himself as affected, at a particular moment in the temporal
deployment of his existence.

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A Renewed Clinical Practice1


These new openings, made possible by some of the discoveries in contemporary neurosciences can be
put in parallel – without however falling into the trap of analogy – with the move beyond previous
structural logic made by Lacan with his conceptualisation of a ‟Borromean” clinical practice. Indeed,
that the of the Name-of-the-Father, or more specifically of the father as means of bringing into being a
nominative, did not have exclusivity in occupying the place of the quarter knot in the Borromean
intertwining, redefines the qualitative distinction made by the antagonistic combination ‟paternal
metaphor – foreclosure of the Name-of-the-Father”. Opposite the first dialectic between neurosis and
psychosis there is nevertheless a homogeneity made by the ‟the fundamental hole that came out with
the symbolic” (Lacan, 1976, p. 36) constituent of the ex-sistence that, itself, belongs to the real. There is
therefore a Verwerfung common to all the structures, the foreclosure of that which, in the real, makes a
hole; and in the face of which the structure (be it neurotic or psychotic) would try to make remedy
through different occurrences of the fourth knot. This is a redefining of the symptom as that which the
subject has that is most real, thus placing it as common to all the structures.
We find here Canguilhem’s hypothesis according to which illness is an adaptative response of the living
being, the setting up of new norms; neurosis and psychosis would both be ways of dealing with the real
– opening up the way to an ethic not of the cause but of the answer found by the subject. Normality,
defined by Freud as alloplastic, might be one of those answers, but it would not itself avoid the
structural Verwerfung of the real.
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Thus, to the question of the ending of analysis, the answer given by Lacan overthrows all
psychopathological nosography, for after having asked himself if Joyce ‟was mad” he ends up stating
that he would be ‟the best one achieves at the end of an analysis” (Lacan, 1976). The aim therefore of
psychoanalysis is the abnormal, in so far as the ideal represented by Joyce is the individual who invents
his own norm; since with the ego of the artist that names himself, he has found a fourth knot other than
the father. This psychoanalytic clinical practice centred on the subject’s ways of responding finds its
echo in the statement made by Canguilhem according to which illness is ‟an alteration such that it
constitutes a new way of life for the organism, new behaviour which prudent therapy must take into
account by not treating the tension at an unpropitious moment in order to bring it back to the norm”
(Canguilhem, 1991, p. 84).

Conclusion
From this overview, we can conclude that the antagonistic pairings of neurosis-psychosis and normal-
pathological, despite some alliterative confusion, cannot be superimposed on each other, nor with the
terms mental health or madness. Thus, the psychoanalyst, within the specific set up that is the
psychoanalytic technique, can only study the unique answer brought by the subject, an answer above
and beyond all the elements that determine him. It is right therefore, to point out once again, the
radical shift made by Canguilhem against the positivism that still dominated the experimental medicine
of his age, which was grounded in a paradigm of the gaze, and observation.
For Canguilhem there is no illness without a patient who is ill, since clinical practice ‟...puts the physician
in contact with complete and concrete individuals and not with organs and their functions.”
(Canguilhem, 1991, p. 88). The origin of the idea of illness should therefore be sought in human
experience taken as a whole. Thus it is first necessary, in order that any meta-psychological
understanding inherent to psychopathology can emerge, that the subject feel ill, describe himself as ill;
and that he therefore addresses his request to a psychoanalyst, with a complaint pertaining to a
symptom.

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If ‟The doctor is called by the patient” (Canguilhem, 1991, p. 226), we need to transpose this principle
relative to the inaugural place of the request, into the analytic set up.
Canguilhem, in opposition to the experimental physiology of Claude Bernard had contributed to
reintroducing the primacy of clinical practice. Furthermore, there exists for Canguilhem a primacy of the
point of view of the patient, which it is equally necessary to assert in the field of mental suffering. Thus,
when President Schreber, in his Memoirs of a Neuropath (1893), proclaims that he is sound of mind, and
demands to be let out of the Leipzig clinic, this point of view should not be contradicted by any external
observation, even if it is medical, (in addition, the function of the exception in psychosis can shed a
different light on the question of a norm, when the subject himself defines himself as beyond the norm).
Similarly, Joyce does not seek an analysis, since he feels no need for one, the ego of the artist who
names himself functions as a substitute for the deficiency of the bringing into being of the naming
father. We can in this way reaffirm that even in the field of mental suffering, it is the subject that feels,
who says whether he is ill or not; and that the central place held by the word of the being-who-is-ill
automatically excludes, in the eyes of psychoanalysis, any psychiatric clinical practice of observation in
which it would be up to the doctor to judge the existence, or not, of illness in his patient. Thus, a serious
neurosis can lead the subject to call himself ‟mad” or ‟ill”; whilst a psychotic who is stable will have no
reason to consult an analyst. The psychoanalyst, in his practice, has in actual fact very little to do with
the normal, but rather with as many singular norms as are established by the subjects he meets. To
resist the pressure, that a culture of the ‟civilised sexual norm” exercises on the psychoanalyst, pushing
him to correct, to normalise his analysands (even if that were possible), turns out to be the teaching that
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we could take from reading Canguilhem.

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Notes:
1
This expression [Une clinique renouvelée] is borrowed from a chapter of the same name by Colette Soler (Soler, 2009).
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