1 Whether in somatic medicine, psychiatry or psychology, a plurality of judgments are articulated and constantly re-hierarchized by caregivers when they are “at the bedside” of their patients. The therapeutic act mobilizes a multiplicity of skills and knowledge, indexed at different levels of practice: the clinical state of the people concerned, the ethical stakes of the care relationship, and the concern for effectiveness of the proposed treatments.

2 In L’Émergence de la médecine scientifique, Anne Fagot-Largeault and Vincent Guillin emphasize the complexity of medical decisions, which are subject to numerous constraints in a context of uncertainty:

3

Conceived in a long historical perspective, the development of medicine appears to be punctuated by the coexistence within it of an emergency […] and a lack […]. The emergency is that of caring for the one who suffers, here and now, so that the suffering stops and the patient gets better. The lack is that of a sure knowledge which would make it possible to identify the evil every time, to know what causes it, to stop its progression, and to treat the suffering or the damage it has caused. [1]

4 Clinical knowledge has evolved considerably since the inaugural prescriptions of Hippocrates to the “recommendations of good practice” now promoted by evidence-based medicine (EBM). It has also evolved according to the new sub-disciplines of care (psychiatry, psychology, and psychoanalysis). But a common vectorization brings together in globo the various forms of clinical approach: the increasingly asserted epistemic withdrawal from the singularity of therapeutic situations.

5 Limiting oneself to the knowledge of single cases of disease was no longer sufficient when it came to treating in series – or even in mass. Identifying common traits, typologizing, and then understanding the “laws” that constitute pathologies – or, failing that, the statistical probability of their appearance and the chances of success of their treatment –has thus gradually become a major challenge, with the consequence of an ever clearer desingularization of clinical thought and acts of care.

6 Psychoanalysis, founded at the turn of the nineteenth and twentieth centuries, is part of this trend. Like the other clinical sub-disciplines, it seeks to increase in generality and to accumulate knowledge, in order to raise its chances of effectiveness: this is shown by its diagnostic, etiological or metapsychological concepts, which are intended to describe/explain cases in series, in order to better operate with each of them in particular. But the Freudian invention presents a characteristic that sets it apart from other approaches. It adopts, in fact, simultaneously with its “increase in generality”, an epistemo-clinical approach that can be designated, conversely, as “increase in singularity”.

7 In somatic medicine, psychiatry or psychology, singularity is certainly also the object of forms of knowledge linked to clinical ethics –patients always being one of a kind. But this ethico-epistemic dimension of uniqueness remains in the background, the search for general treatments being electively valued and promoted. For psychoanalysis, on the contrary, the singularity of the patient – as well as that of the analyst and of each of their encounters – is not only the ethical foundation of care, but also the privileged objective in terms of research. The inequivalent, the non-substitutable, the non-reproducible –that is to say, what signs psychic uniqueness in the strongest sense, to be re-analyzed for each patient at the end of each session – is indeed very quickly considered by Freud as the most effective therapeutic lever in cure, and therefore what needs to be thought most rigorously –in the scientific sense –in order to provide the best treatment.

8 If we assume that “clinical thought” is historically the site of a tension between the singularity of therapeutic situations and the generic of their theorization with a view to the effectiveness of care, psychoanalysis then appears as a paradoxical sub-discipline, pushing as far as possible the concomitant investment of two opposing logical poles: both the generic (metapsychology) and the typical (diagnosis, etiology); and, equally, the radical singularity (with the unique features of cases).

9 Through this epistemological position “at the limit”, psychoanalysis contributes to an innovative re-problematization of the question of operative logical levels, crucial from a therapeutic point of view. Is it above all at the level of the generic (as in medicine) that we must situate the effort of truth in order to treat well, at the level of the typical (as in psychology), or, on the contrary, in the order of the unique (an original proposal of psychoanalysis)?

10 To clarify this problem, we propose to circumscribe, first, the historical tension between the logical levels of the singular and the generic in the main clinical disciplines (somatic medicine, psychiatry, psychology), whose general tendencies indicate an ever more pronounced de-singularization/standardization of thought and practice.

11 Secondly, based on a famous case of Freud, we will try to restore, by comparison, the originality of psychoanalysis, at the turn of the nineteenth and twentieth centuries. Indeed, Freud very quickly noticed a progress in the efficiency of the treatment of the “nervous” thanks to a collaborative epistemic work on their singular psychic experiences. He was then clinically obliged to reverse the dominant hierarchy: the “thinking in laws” in psychoanalysis lost its relevance to the benefit of “thinking in cases” [2].

12 Through this counter-current gesture, Freud imported a mode of reasoning close to that of the nascent human sciences, in a field (health care) increasingly linked to laboratory research (experimental approach) and to the perspective of large numbers (epidemiology). The new kind of clinical scientificity promoted by psychoanalysis, hybridizing multiple schemes of thought elaborated from therapeutic practice, then makes possible the extension of their application to other types of phenomena, not clinical strictly speaking, but in intimate relationship with the “human” (cf. in history, ethnography, morality, literature, art). This is why some people propose the extension in return of the qualifier “clinical” to all “human” knowledge of the singular – a point we will discuss in conclusion.

Efficiency Through Typical-Generic Knowledge: Somatic Medicine, Psychiatry, Psychology

13 The traditional figures of clinicians – the somatic physician since Hippocrates, then, from the nineteenth century onwards, psychiatrists and psychologist practitioners –have historically been associated with a keen sense of observation of pathological phenomena in their singularity, coupled with a mastery of more general empirical data, extracted from the series of cases encountered. Receiving patients, identifying semiological elements, determining an etiology, a diagnosis, a prognosis, and then treating the suffering people in the best possible way are all based on attentional and theoretical skills in the field, “on a human scale”.

14 However, the progress of science from the nineteenth century onwards, in particular the success of the experimental device, and then the rise of statistical and epidemiological approaches, gradually transformed what “clinical thinking” and “care” traditionally meant. In the name of scientific progress (and of greater expected efficiency), other modes of attention and reasoning than those of the group of clinician-researchers in front of their patients have progressively imposed themselves from the laboratory. In somatic medicine, in psychiatry, and then in psychology, the singularity of patients’ cases has thus been partly disinvested, in a quest for truth reindexed to the nomological ideal of experimental sciences.

The Laws of Bios and Large Numbers: Bernard, Pasteur and Translational Medicine

15 In somatic medicine, two names in the nineteenth century symbolize the victory of the laboratory over the traditional clinical approach and the introduction of new (extrinsic) ways of thinking “at the patient’s bedside”: Claude Bernard and Louis Pasteur.

16 In his Introduction to the Study of Experimental Medicine, criticizing the “backward state” [3] of medicine, plunged into the “shades of empiricism” [4] and recalling that “[it is in the laboratory] that the man of science withdraws, and by means of experimental analysis tries to understand phenomena that he has observed in nature” [5], Bernard defends the project of a knowledge of the underlying biological mechanisms of diseases:

17

A physician’s subject of study is necessarily the patient, and his first field for observation is the hospital. But if clinical observation teaches him to know the form and course of diseases, it cannot suffice to make him understand their nature; to this end he must penetrate into the body to find which of the internal parts are injured in their functions. That is why dissection of cadavers and microscopic study of diseases were soon added to clinical observation. But today these various methods no longer suffice; we must push investigation further and, in analyzing the elementary phenomena of organic bodies, […] all psycho-chemical conditions which contribute necessary elements to normal or pathological manifestations of life. [6]

18 In his Principes de médecine expérimentale, Bernard thus opposes the truly scientific knowledge of scabies with the merely clinical knowledge of fever. In the first case, the cause of the infection was known, i.e. a type of mite (acarus scabiei), which made it possible, by eliminating it with sulphur, to completely cure the patient of their skin disease, in a form of “scientific law” [7] of care. In the second case, we only know that giving cinchona works relatively well (the temperature disappears in most cases), but nothing has been understood about the pathological mechanism, nor about the causes of the improvement or the cure. The traditional clinical approach is limited in the understanding of diseases, for Bernard, because the number of questions it can ask and validate in a rigorous (notably reproducible) way is smaller than in the artificial and controlled space of the laboratory. On the other hand, for Bernard, statistical thinking is not the place for a satisfactory medical science either, being as it is, incapable of determining precisely the physio-pathological mechanisms at play “in all real [8] cases”.

19 Around the same time, the reception by general practitioners of Pasteur’s work (in bacteriology and immunology) made it possible to measure this transformation of the medical field. As Bruno Latour has well analyzed in Pasteur: guerre et paix des microbes, the traditional clinic was then strongly depreciated from the point of view of the quest for scientific truths, in the name of the possibilities offered by the laboratory and their repercussions in terms of efficiency. [9] Clinicians became aware of this, but not without difficulty. It is an expert view other than their own that will henceforth recommend “good practices” to them, in the privacy of their offices. A text by Dr. Hippolyte Jeanne –“La bactériologie et la profession médicale”—in 1895 reflects this situation well, naming very precisely the important changes at work:

20

It is perhaps not too early to take a look at the future of the medical profession in the wake of the scientific revolution brought about by the beneficial discoveries of the illustrious Pasteur and his school. […] Surgery and hygiene have been conquered: the medicine of the past is no longer able to dispute the field. Diagnosis, this primordial element of our art, will soon no longer be able to do without the microscope, bacteriological or chemical analysis of cultures, inoculations, in short, everything that can provide our assessments with absolutely accurate data. But what will then become of medical flair, of the je ne sais quoi that we believe we can put forward, and of experience, this guarantee that the public demanded of our gray hair? […] [W]hen the struggle for existence begins, between us and these young people armed with a knowledge different from ours, […] are we not threatened at short notice with a crushing and irremediable defeat? Will the public be for us? [10]

21 The blatant sincerity of the text makes it a unique document on the changes in medicine at the end of the nineteenth century. Indeed, what is at stake here, after the pioneering research of Pierre-Charles Louis, Claude Bernard and other physicians of “quantitative” [numériste] and experimental spirit, is the passage from an “eminence-based” [11] paradigm, based on the authority of “gray hair”, i.e. personal experience (crossed with that of peers), to an “evidence-based” paradigm, based on the interpretation of “absolutely accurate data”, drawn from controlled research protocols, most often conducted on large cohorts of cases in laboratories, by non-“clinicians” (in the classical sense of the term).

22 This text, taken from a journal for health professionals, shows the extent to which what has come to be called “translational medicine” –that is, the experimental-clinical approach that goes from “bench-to-bedside of the patient” [12]–has been in preparation since the nineteenth century, requalifying traditional research (anchored in the care relationship) as “pre-scientific residue”, except in the cases (apart from those) of rare or hyper-complex diseases, which still require it today. [13] What so-called “scientific” medicine seeks to achieve (based on the extra-clinical, i.e. partly emancipated from the traditional “human” dimensions and measures) is reliable knowledge that is common to all possible cases, and not indexed only to the idiosyncrasies of singular situations. To this end, it must be removed from the context of the care relationship and reconstructed in the decontextualized space of the laboratory or of epidemiological thought, by means of a set of controlled variables, extracted from the patients or their disease.

23 The major milestones are as follows:

• 1948, first randomized controlled trial; [14]
• 1992, evidence-based medicine (EBM) paradigm, prioritizing all existing treatments according to their statistically convincing value; [15]
• 2000, idea of a new “translational” clinical spirit, essentially indexed to laboratory results, launched by the American National Institute of Health, then taken up by international public health recommendations, which serve as guidelines for most of the countries in the world. [16]

24 Currently, in medicine, among the experimentally controlled treatments are promoted those that are statistically applicable to the greatest number. The de-singularization of scientific truths constitutes the highest level of evidence, according to the model of a “clinic oriented by extra-clinical research”, which has now supplanted, with a certain number of exceptions, the traditional model of “clinically-oriented research”.

25 It is a very strong redefinition of what “clinical thought” and “care” mean, which in turn modifies the contemporary epistemic content of the medical act in a technicist-operative [17] sense, not without controversies of various kinds. [18]

Psychiatry and Its Nomological Approach to Mental Illnesses

26 Such a laboratorization of clinical thought, in somatic medicine, has undeniably enabled great advances in terms of knowledge and the reliability of treatments. This is also why, in psychiatry, the nomological ideal has never ceased to be regularly replenished, despite the lower incidences in scientific and therapeutic terms. Moreover, the so-called “mental illnesses” having for a long time offered little scope for laboratory research, it is the statistical approach (epistemically weaker) that has historically prevailed when it comes to finding “laws” for care – that is to say, of going beyond the strictly “clinical” achievements of the singular conversation between the patient and their psychiatrist.

27 We owe it to Steeves Demazeux to have been able to highlight, after the work of Theodore Porter, the pioneering attempts of French psychiatrists to characterize the different types of “madness” [19] with the help of quantifiable and statistically operable items. From Pinel to Lisle, including Esquirol or Leuret, those who were the first great physicians of human madness accompanied their semiological and typological work of classical clinicians with innovative quantitative investigations, intended to isolate the cross factors of the onset, development and/or remission of psychiatric disorders. The goal was to better understand the objectifiable causes of each of them, in order to better treat them. Thus, Pinel wrote, in Résultats d’observations et constructions des tables pour servir à déterminer le degré de probabilité de la guérison des aliénés (1807) that psychiatry “can only take on the character of a true science by the application of the calculation of probabilities” [20]. His pupil Esquirol continues in this direction:

28

There are doctors of good faith who do not like statistics? Have they really reflected that the sciences of observation can only be perfected by statistics? What is experience, if not the observation of facts repeated often and committed to memory? [21]

29 Throughout the nineteenth century, however, such initiatives did not lead to better treatment of mental illnesses as much as had been hoped. Here we find again the question of the logical levels operating in the clinic, with this fundamental problem that keeps unfolding as soon as we leave the more “stable” ground of the biological body (which is common to the species): do average statistical data concerning psychiatric disorders allow us to grasp the “real” articulations of these disorders, on a case-by-case basis? In other words, from an ontological point of view, do the different kinds of “mental disorders” have generic articulations, common to all patients suffering from the same disorder, and thus graspable if not by shared mechanisms, at least indirectly by means of statistics, or, on the contrary, are their “deep” articulations above all singular?

30 If we turn, during that same period, to the organogenetic approaches to psychiatric disorders from medicine, we see that they in fact offered few scientific advances, except for neurological diseases. They did not open up any great therapeutic prospects either, neuropharmacology and neurosurgery being underdeveloped at the time. This is why psychiatry, a medical specialty “apart” from all others, long remained “clinical” in the traditional sense of the term. [22]

31 It was not until the 1970s that the singular encounter between the patient and their psychiatrist, at that time highly steeped in non-medical psychological and/or psychoanalytical knowledge, was once again reinvested by scientific knowledge with a nomological ambition. The need for epidemiological surveys in the United States led to a renewal of statistical thinking in psychiatry, which required an operationalization of diagnoses [23] that resulted in the third version of the Diagnostic and Statistical Manual of Mental Disorders (DSM) [24]. In the Anglo-Saxon world of the 1980s, the whole of classical psychiatric reasoning was gradually transformed by the importation of algorithmic ways of thinking about patients (checklists, decision trees).

32 Meanwhile, since the 1960s, chemotherapy has developed with the discovery of new psychotropic drugs. According to Steeves Demazeux, the neuroscientific understanding of the mechanisms of action of these drugs led to the hope of a “slow and profound conceptual reorganization […] between psychiatry and the ‘brain sciences’ [25]”. The postulate is the following: human brains (like bodies in somatic medicine) present particularities linked to natural evolution which could, if they were well understood –and beyond the inevitable individual variabilities – allow for a better treatment of psychiatric patients than the case-bycase approach and the human understanding of the patient, of their life history, of their own resources and fragilities. This perspective marks the beginning of the decline of the old clinical tradition in psychiatry, based on the observation and understanding of the people suffering. Paul Bercherie pointed this out in 1985 in his Histoire et structure du savoir psychiatrique: “For several decades now, psychiatry has begun to be ashamed of pure clinical practice, of simple observation, of the gaze […]”. [26]

33 Since the “decade of the brain” [27] (1990-2000), neuropharmacological and neurosurgical approaches have gained more and more weight in psychiatric theory and care, to the point of having relegated to the background, in the name of an efficiency presumed to be superior, any undertaking to recapture and support the singularity of patients, which sometimes designates itself, to mark its difference, as a project of “artisanal psychiatry.” [28]

34 The Rdoc research program, initiated in 2009 by the American National Institute of Mental Health, [29] confirms the current theoretical hegemony of the neuroscientific axis in psychiatry, although the care of patients with so-called “mental” disorders continues to show a certain resistance to its laboratorial control, probably in view of the bio-psycho-social complexity recognized elsewhere. [30]

The Slow Conquest By Large Numbers of the Psychological Clinic

35 In psychology, the current laboratorization of clinical thought is also linked to the development of brain sciences in recent decades, as well as to the broader cognitive neurosciences. [31] Historically, in the nineteenth century, psychology was certainly born as an experimental discipline, through psychophysics (Fechner, Wundt) or psychometrics (von Helmholtz, Hirsch, Galton, Mckeen Cattell, Binet) [32], but such sub-disciplines were of no help in the field of health care – their partial numerical results, produced in the laboratory, being unsuitable for grasping the most decisive aspects of psychological life from a therapeutic point of view.

36 Alongside experimental psychology, there existed a so-called “clinical” psychology, which was devoted to the understanding of psychic mechanisms based on studies of single cases, put in series. [33] The therapeutic effectiveness sought on a case-by-case basis for patients and their singular symptoms then gave rise to a certain accumulation of knowledge, always mindful, however, of the individuality of the psyche. [34]

37 In psychology, the de-singularization/standardization of clinical practices did not become prevalent until the 1980s – and first in the United States –with certain key stages:

• in 1924, following John Watson’s behaviorist experiments on animal [35] and then human [36] conditioning, Mary Jones “applied” this emerging science to little Peter (2 years and 10 months old) to free him from his fear of rabbits, by desensitization; it was the first behavioral therapy; [37]
• in the decades that followed, the so-called “Boulder” [38] model encouraged psychologists to use techniques with their patients that had been conceptualized and tested in the laboratory, and then formalized for the “patient relationship” [39]; for “modern” clinical psychologists, this meant being “scientist-practitioners” [40];
• this seminal project of “behavioral engineering” [41] then developed, with, for example, the invention of the Applied Behaviour Analysis (ABA) method, developed by Ole Ivar Lovaas, which he applied to autistic disorders for the purpose of rectifying their behavior; [42]
• the birth of cognitive sciences, in the 1950s and 1960s, made it possible to make this experimentalist approach to the clinic more complex and flexible, by introducing “cognitions” between stimuli and behavioral reactions; [43] this gave rise – in the 1970s – to cognitive-behavioral therapies (CBT), based on the updated theories of learning; [44] the techniques used (until today) are those of cognitive restructuring, de-sensitization by exposure, training in social skills, modeling (identification with successful models) –all techniques initially conceived (and then tested) in the laboratory, making it possible to pursue the nomological ideal of a “generic reshaping of behavior”. Cognitions are themselves seen as forms of objectifiable (internal) “behaviors”, caused by neural mechanisms common to homo sapiens, and therefore justifiable by standard treatments –CBT, in this case. [45]

38 We must then go back to the very end of the last century to see a redefinition of what “treating” means in psychology, in the footsteps of the medical model and at the same time with similar changes in the psychiatric field. Robert McFall, in “Manifesto for a Science of Clinical Psychology”, echoes a strong tendency in clinical psychology to devalue the classical approach, ordered to the singular encounter with patients: “For clinical psychology to have integrity, scientific training [of an experimental and/or epidemiological type] must be integrated across settings and tasks.” [46]

39 The underlying ideal, which is only that of Watson’s (updated) behavioral psychology, consists in putting an end definitively, in the long run, to the figure of the psychologist-therapist who is autonomous in their clinical behaviors (although indexing them to recognized knowledge). Indeed, if the effective knowledge in the real world has basically nothing to do with the subjectivity and the style of the clinician, classically necessary to recapture the patient’s subjectivity – but less useful from the point of view of a (translational) model proposing to clinically implement generic laboratory truths–why continue to use beings endowed with a singular psychic life to treat? They can only be less rigorous and formal in their action than are artificial intelligences programmed to “treat”.

40 Simon and Ludman make it possible to measure the new mutation. In “It’s Time for Disruptive Innovation in Psychotherapy”, in 2009, they record the pre-eminence of standard theoretical models (from the laboratory) over the (singular) therapists who are supposed to apply them. This opens up the perspective, now expanding, of computerized virtual therapies, without the concrete presence of therapists. [47]

41 Four years later, in another article published in the equally prestigious American Journal of Psychiatry, the same authors push their reasoning further, in a drastic alignment of scientific psychology with experimental medicine: in everyday life, according to them, we prefer the local and the singular for certain things (organic popcorn, for example, which tastes like it came from the field next door) but the decontextual and the standard for other things (the brakes of our cars). Conversely, factory-made popcorn seems tasteless, and the brake cobbled together by a craftsman in his personal garage is unreliable for preserving our lives on the road. From the point of view of our health, as well, we certainly prefer, still according to Simon and Ludman, standard laboratory-controlled medicines and surgeries rather than home-made remedies and interventions. So why not for psychotherapy? This is the provocative question they feel should be asked:

42

Are mental health treatments more like sweet corn or automobile brakes? We would usually put medication treatments in the latter group, where we value uniform quality over one-of-a-kind craftsmanship. The recent meningitis outbreak traced to a compounding pharmacy only reinforces the argument for “factory-made” pharmaceuticals. A centralized and standardized production process for medication will generally improve both quality and safety. But we have traditionally considered psychosocial interventions (like care management or actual psychotherapy) to be more like artisan bread than auto brakes. We prefer our psychosocial interventions to be locally grown, hand-made, and one-of-a-kind. [48]

43 Simon and Ludman give us a dazzling overview of the trends currently at work in the psychological field. Rather than the craftsman of care, trained by clinical experience and critical intersubjectivity within a shared field of research, the dominant scientific requirement expects the psychologist to be an expert, capable of applying the most effective techniques tested in the laboratory, according to a paramedical model of care –psychotherapies being conceived as being administered like “medicines”.

44 The Delaware project, contemporary successor to the Boulder model, and now inspiring many universities around the world, acknowledges this redefinition of the profession of psychologist. The practitioner is called upon to receive scientific training in “care management” [49], in order to “shape better results” [50] for their patients, who are then thought of primarily as particular cases of types of diseases.

45 In short, the clinical psychologist of the future could become more and more a psycho-technician who applies as best they can the “recommendations of good practice” elaborated by others (such as the Haute Autorité de Santé in France), based on results produced outside the clinical situation of care. The singularity of the patients, indexed to their own psychic life, to their memory, to their ideals, to their subjective positionings –singularity that they address to one clinician and not to another –would then no longer appear as the most relevant nor, supposedly, the most efficient logical level (which remains to be proved) [51].

46 In this new “translational” perspective, one would no longer treat a phobic patient with a specific history in a specific life context, but “a” phobia, supposedly common to other “patients” of the same type, identified in each of them as a symptom without context, by means of a standard set of techniques deemed to be effective for “all” phobias. As for the singularity of the clinician, it would also be pushed into the background, as most of the effectiveness is supposed to be linked to the constantly updated standard protocols that they should use.

Efficiency Through the Unique in Psychoanalysis: the Example of Lucy R.

47 In light of this overview of the historical trends of “clinical thought”, one sub-discipline clearly appears as being against the current in the field of care: psychoanalysis. If, like the others, it increases in generality to act, it adopts at the same time an opposite approach. In the name of the sought-after therapeutic effectiveness, which implies the greatest finesse in the identifications relating to psychic life, it increases in singularity.

48 However, psychoanalysis was not born all of a sudden. It is the methodological and then theoretical consequence of a coherent progression on the part of Freud, [52] who moreover was able to convince some of the somatic physicians, psychiatrists and psychologists themselves (especially among therapists) of his “good reasons”, in his time as today.

49 Let us briefly outline the path taken. Initially trained in medical reasoning (semiotypological), Freud assimilated as a psychotherapist the principles of nascent clinical psychology, which he re-theorized, in order to distance himself from experimental psychology, into a holistic model known as “psychodynamic”. This gesture allowed him to postulate the existence of an individual psychic apparatus in each person, in addition to the already known somatic apparatuses (digestive, visual, motor), and thus to legitimize the taking into account of a complex, stratified psychic life, partly autonomous with respect to the laws of operation of its own biological substrates –that is to say, indebted to other descriptive/explanatory/predictive logics. From there, objectifying the material of speech collected in session (according to the clinical device of free association), he infers a set of non-conscious thought processes breaking with spontaneous psychological reflexivity (naive psychology, of introspective type). Finally, he assumes a postulate of universality for the processes of psychic life, conscious as well as unconscious, by methodological decision open to possible revision. [53]

50 The identification of these processes, such as defense mechanisms, for example, allows him to renew the etiological hypotheses of certain disorders, in particular (psychogenic) disorders considered as “neurotic”, “narcissistic”, “perverse” or “psychotic”, except for somatogenic disorders, for which the etiological equation is different. The clinically observed effectiveness of psychoanalytic practices validates in return, to the extent of the rigor of the evaluations produced, the robustness of the disciplinary concepts, i.e. the fact that they identify a form of psychological “real”.

51 Pushing further his project of understanding psychic life, Freud is finally led to situate at the level of what could be called the “unique operative representations” the mainspring of any psychoanalytic cure. These representations are specific to each patient, non-reproducible, and require a long and difficult work of uncovering them: the analytic cure, in short. It is in this sense that Freud, in From the History of an Infantile Neurosis (1918), distinguishes psychoanalysis from “old-fashioned psychotherapi[es]” [54]: in the precise sense that an analytic cure “reaches [a] peak” [55] from the point of view of the precision of epistemic identifications and, thus, supposedly, of therapeutic effects.

52 In the same way as the other clinical sub-disciplines, psychoanalysis thus increases in generality in order to operate better: it requires a diagnostic and etiological horizon, and typological and generic reference points. But, contrary to these, and at the same time, the Freudian epistemo-clinical invention consists in increasing in singularity in order to act –which his “main residence” [56] allows him to meet at the heart of the encounter with patients, in the intimacy (finely supported by speech) of the clinical situation. Ultimately, it offers a form of care like no other.

53 It is this paradoxical status that we must now re-examine on the basis of a concrete case of therapeutic work described by Freud –that of Lucy R. –from which we will then try to draw lessons for a more precise understanding of the controversies that are currently raging within the clinical field – particularly the psychological field.

The Case of Lucy R., or Uniqueness in the Service of Efficiency

54 Why discuss the case of Lucy R., taken from Studies on Hysteria (1895)? It has a double advantage for us: short, but sufficiently detailed, it allows us to increase in singularity with Freud, by following his thought; moreover, taking place in his house before the official birth of psychoanalysis, he accounts for the “analytic” style of reasoning without excessive overtheorization, delivering it to the reader in its simplest form.

55 Of course, a-theoretical therapeutic practices do not exist. And we must keep in mind what serves as a preconception in Freud, in the 1890s, with regard to his approach to treatment. As a reader of the psychotherapeutic literature of the time, and armed with his own early experiences (such as his inaugural cure of Emmy von N.), Freud was open to the common idea that certain disorders described as “psychogenic” were rooted in the singular soil of psychic life. Exploring the multiple layers of which this ground is made up, for Freud as for other clinicians of his time, is therefore likely to be effective in improving the symptoms that led the patients to consult.

56 What is the context of Lucy R.’s treatment? A young woman in her thirties came to Freud for problems that her first doctor had been unable to treat. Negative symptoms: complete loss of the sense of smell, fatigue, depressed mood, decreased appetite. And a positive symptom: an olfactory perception that sometimes comes to her and pursues her, without any identifiable external object. The nose, notes Freud, does not present any anatomical or lesional problem.

57 In an alternation of logical approaches by the typical side of the symptoms and then by the uniqueness of certain affected representations specific to the patient –the latter taking up more and more space in practice and, therefore, at the level of the texture of the clinical narrative – Freud experimented with and proto-theorized a new form of psychic care, which would take on, the following year, the name of “psychoanalyse” in French in the text. [57]

58 Freud first asks his patient to describe the smell she perceives, since this is the problem with which she presents herself to him. Lucy R. answers that the smell is “of burnt pudding” [58]. This affected representation belongs singularly to the one who utters it. To apply a generic knowledge, as Freud does at first, by reclassifying the phenomenon experienced as a “subjective olfactory sensation” [59] (then later as a “slight and mild hysteria” [60]), is scientifically important (in the order of knowledge), but quickly proves to be of little help from a therapeutic point of view – the diagnosis not being associated with any standard treatment, a priori applicable (contrary to what takes place in medicine).

59 In order to understand what this symptom is supposedly the effect of, and thereby to try to identify certain causes, it seems appropriate to Freud to trace the associative threads back to the psychic soil of its hypothetical genesis. He begins the treatment, starting from the first thread stretched by his patient: “I therefore decided to make the smell of burnt pudding the starting-point of the analysis.” [61]

60 In psychotherapy, then as now, everything that is known to work sometimes is to be considered. Hypnotic suggestion, which can be rendered as the act of authoritatively asserting to a patient (put in condition) that their symptom will disappear, is one of the tools already used with some success by Freud, although this, by his own admission, was mixed.

61 He tries this with Lucy R. but it fails with her. He then suggests that she lie on her back, concentrate and try to answer his questions about the unpleasant smell. However, each time he asks her (“How long have you had this symptom?”; “What was its origin?”), the patient responds with a “I really don’t know.” [62]

62 Postulating that she knows without knowing that she knows –because a psychic association must indeed exist in her, this is the proto-theoretical postulate –he insists, by putting pressure on her head: “you will see something in front of you or something will come into your head. Catch hold of it. It will be what we are looking for.” [63] With the help of these indirect suggestions, he ends up bringing back to her the memory of the scene where the smell of pudding first appeared:

63

It was about two months ago, two days before my birthday. I was with the children in the schoolroom and was playing at cooking with them (they were two little girls). A letter was brought in that had just been left by the postman. I saw from the postmark and the handwriting that it was from my mother in Glasgow and wanted to open it and read it; but the children rushed at me, tore the letter out of my hands and cried: “No, you shan’t read it now! It must be for your birthday; we’ll keep it for you!” While the children were having this game with me there was suddenly a strong smell. They had forgotten the pudding they were cooking and it was getting burnt. Ever since this I have been pursued by the smell. It is there all the time and becomes stronger when I am agitated. [64]

64 Freud, however, does not understand why the arrival of a letter from her mother could have such an effect on the patient (having “caused” the insistent smell in her). From the point of view of her outward description, this scene is quite banal. Having asked her what could have put her in such an emotion, she replies: “I was moved because the children were so affectionate to me.” [65]

65 The answer sounds like a banality, that is, a general idea that could apply to anyone in any circumstances. Freud is not scientifically satisfied. Are children, by the way, not “in general” always so tender towards her? And the patient replies: “Yes –but just [more so] when I got the letter from my mother.” [66]

66 Freud remains skeptical. He conjectures a conflictuality in the patient’s subjective position (the only way to understand the emotion described), but without knowing precisely where it could be located. Lucy R. finally explained herself: “I was intending to go back to my mother’s, and the thought of leaving the dear children made me feel so sad.” [67]

67 A form of conflict is certainly stated in relation to the mother, but Freud still does not understand the psychological sequence. There is nothing there that seems to be able to take on a traumatic value, to the point of leading to the symptom addressed to him as an enigma. Pulling the new thread brought by his patient, he inquires about the maternal question with regard to her: “What’s wrong with your mother? Has she been feeling lonely and sent for you? Or was she ill at the time, and were you expecting news of her?” [68] But Lucy R. refutes this: “No; she isn’t very strong, but she’s not exactly ill, and she has a companion with her.” [69] Duly noted.

68 Freud then tries to explore the trail of the children, to see if a latent intensity might not be hidden there, pointing towards an initially unsuspected psychic “real”. Why did she have to leave the children? The letter does not necessarily imply it. At this point, Lucy adds that the atmosphere at work had become poisonous. The rest of the household staff had ganged up on her, so she had resigned. When the letter arrived, she associated it with the fact that she would soon go home to her mother and stop seeing the children for good. Freud’s next attempt: “Was there something particular, apart from their fondness for you, which attached you to the children?” [70]

69 Suddenly, the cure is accelerated. A wealth of clinical material appears. On her deathbed, the employer’s wife (who was a distant relative of Lucy R.) had asked her to promise that she would take care of her own daughters with all her might, that she would not leave them and that she would replace her for them. The patient is now able to conscientize this, bringing to light a first layer of intrapsychic conflict: “In giving notice I had broken this promise.” [71]

70 Freud then summarizes the progress of the analysis. The trauma, associated with the smell of pudding, would be born of a conflict between the letter from her mother (associated with her departure, itself associated with her resignation) and the promise made to the mother of the children to stay with them. There would thus be a psychic irreconcilability of two representative complexes. Such an interpretation seems to him narratively attractive, but scientifically weak, in that it still feeds too much on psychological generalities (it sounds like a rather common conflict) and proves to be incapable of explaining the intense, precise – and, for him, supposedly unconscious – subjective drives of the pathogenesis:

71

But I was not satisfied with the explanation thus arrived at. It all sounded highly plausible, but there was something that I missed, some adequate reason why these agitations and this conflict of affects should have led to hysteria rather than anything else. Why had not the whole thing remained on the level of normal psychical life? [72]

72 On the basis of the elements at his disposal, Freud then proposes a new construction, more apt according to him to account for the intensity of the subjective conflict:

73

If her fondness for the children and her sensitiveness on the subject of the other members of the household were taken together, only one conclusion could be reached. I was bold enough to inform my patient of this interpretation. I said to her: “I cannot think that these are all the reasons for your feelings about the children. I believe that really you are in love with your employer, the Director, though perhaps without being aware of it yourself, and that you have a secret hope of taking their mother’s place in actual fact. And then we must remember the sensitiveness you now feel towards the servants, after having lived with them peacefully for years. You’re afraid of their having some inkling of your hopes and making fun of you.” [73]

74 Following this, in a dubious, laconic and trivializing way, his patient replies: “Yes, I think that’s true” [74]. Freud then asks her why she has not said so, if she believes it. And Lucy gives him this answer (from which Freud extracts the descriptive concept of “repression”, which later arms his narrative): “I didn’t know – or rather I didn’t want to know” [75].

75 However, Freud is still not satisfied by this apparent docility of the patient. He has still not located in detail the pathogenic excitational intensity. He has still not grasped the determined coordinates of the symptom. According to his experience, there is only an effective de-repression of unconscious experiences if this is psychically followed by a process of change, both on the representational and on the affective level (declarative acquiescence is not enough). But this is not the case.

76 Freud then chooses to follow the trail of Lucy R.’s state of love, recognized by his patient. The latter, as a result, recalled a scene that she thought was very intense, in which, after the death of his wife, the employer looked at her with an extremely “gentle” air, he who was usually so reserved, while telling her that he was counting on her to take care of the two orphans. Very quickly, she would have forgotten this episode, followed by no effect on their real relationship.

77 Freud then conjectures that Lucy R.’s previous inclination for her employer, intensified by the deathbed scene (where the wife asks her to take her place as mother to the children, and thus indirectly as wife to the husband), is revived again –on an internal quantitative level – following the employer’s extremely “gentle” eyes, and then finally takes on a phantasmatic consistency in his patient, that is to say, is knotted into a psychic event that belongs to her alone. He says it to himself in these terms: the gentle look, perhaps, was addressed to the deceased wife, while he was talking about his children, and she will have taken it for herself. He proposes this interpretation to Lucy, to whom, this time, it speaks much more clearly. The clinical effect is quickly objectified: the smell of burnt pudding disappears immediately.

78 A few weeks later, however, a new subjective odor –of cigar, this time –appears, thus substituting one symptom for another. The work is to be resumed, starting from the associative threads where they left off. Let’s cut to the chase. Lucy R., after a few proper sessions and elaborations, finally arrives at a scene that is again very striking for her, where the employer yells at his accountant, who has come to dinner one evening and is going to kiss the children, “Don’t kiss the children!” [76] She is upset by this –it feels like “a stab at [her] heart,” she says. The room is then filled with the smell of cigars.

79 However, Freud notes, the attack is not directed against her. Why then such a psychic echo in her? Would she have thought that if she were her employer’s wife, she would have to endure this too? Lucy R.’s rebuttal: “No, that’s not it.” [77] The treatment therefore continues.

80 A resolving scene of the analysis is finally revealed behind that of the accountant, situated earlier in time: one day, a friend of the employer had come and kissed the children; the employer had waited for the friend to leave and had actually verbally unleashed on Lucy; he had blamed her for such kisses; her duty, according to him, was never to allow that; if it happened again, he would entrust the children to someone else. End of sequence.

81 This scene, the last to appear in the cure, but inaugurating the troubles, had taken place at the time when she was expecting at the highest point from her employer a confirmation of the loving reciprocity that she had believed she could detect in the extreme “gentleness” of his look. She had then understood at this precise moment that he did not love her at all, that he would never love her, that she had made a mistake, with all the consequences of life that this enveloped (she would surely remain the domestic employee that she was, and not the wife of a socially important man). The moment of understanding had been extremely fleeting, and immediately forgotten –or “repressed”.

82 Freud, then, makes a decisive step: for him –and he submits it to his patient –in this scene there occurs the paroxysm of an unconscious conflict, probable psychic source, then, of the recurring symptoms. Wouldn’t it be a question of the unconscious conflict, in her, between a maximum of phantasmatic impulsive excitation and a maximum of refusal in reality. An unconscious conflict because it is repressed (due to displeasure), surfacing surreptitiously in the scene with the accountant, and being triggered fully, by summation of the somato-psychic quantities, with the arrival of her mother’s letter, sealing definitively any possibility of return.

83 A few days after becoming aware of the affective-representational elements of this inner conflict, through psychic validation of Freud’s interpretations, Lucy R. testifies to a decisive shift in her subjective position:

84

When I woke yesterday morning the weight was no longer on my mind, and since then I have felt well. […] I am quite clear on the subject [of my prospects in the house]. I know I have none, and I shan’t make myself unhappy over it. […] I think my own oversensitiveness was responsible for most of that. […] Yes, I certainly am [still in love with my employer], but that makes no difference. After all, I can have thoughts and feelings to myself. [78]

85 In other words, Lucy R. states that she has disinvested a part of her fantasy position, at the same time as she has identified it and faced it. More exactly, she has given her fantasy a place of fantasy (and not of possible reality). She admitted to what is impossible, psychically inscribing the marks of a before and after. The enlargement of her consciousness to what she did not want to know at first – this impossibility, leading to the conflict –allows her to “see quite clearly”, to be more reflective on herself, with the consequence of a disappearance without remainder of her symptoms.

86 We may allow ourselves to say that Freud, for his part, experiments with this: beyond the meager therapeutic consequences of the diagnosis of “slight and mild hysteria”, or of the semiological identification of the “subjective olfactory sensation”, what counts, what it is a question of orienting oneself electively, are the verbalizations in proper name, the memories of lived scenes, the details of these scenes and of all the associated incidental ideas – that is to say, the unique representations of the patients, which he observes clinically to be therapeutically operative.

The Paradoxical Double Movement of Freudian Clinical Thought

87 What should we take away from this pre-psychoanalytic example? We propose to underline the following: what is decisive in Freudian clinical thought is that it restores its full place and its scientific value, in a field of care which is gradually in the process of being extracted from it, to the logical operating level of the singular. This devalues in return, from the strict point of view of psychological care, any research that would cut itself off a priori from this fundamental level – that is to say, any epidemiological research or research that only comes from the laboratory.

88 Psychoanalytic thought, for Freud, must be elaborated from the therapeutic relationship, as in the case of Lucy R., which in fact sanctuaries the singular conversation of the clinician and his patient. The tools of thought that would be conceptualized in the laboratory, from pre-criterized cohorts of cases, could hardly help to grasp what we have designated as “unique operative representations” (the scene of the employer’s unleashing on her; the subjective collapse of her intense ideal of reciprocal love), nor even the clinical typologizations made from some of their shared features (here, the qualification of “hysteria”).

89 But this sanctuarization of the classic clinical situation (the encounter’s terrain) does not lock up thought for all that. The increases in generality are necessary for Freud, starting from the singularity of the material. They are accompanied, moreover, by a postulation of universality. The birth act of psychoanalysis, in The Interpretation of Dreams (1900), takes place, for example, as much through the investment of the uniqueness of the “meaning” proper to each singular dream as through a generic theorization “of the” dream, based on the modeling of a psychic apparatus hypothetically common to all (universal). [79]

90 That being said, with the help of the case of Lucy R., we must go one step further. If the unique representations are operative, for Freud, and thus legitimize in return their epistemic integration within his clinical thought, it is because they are stated in their own name, in the hic et nunc of a truly subjectivized verbalization. Saying yes to the analyst’s interpretation, however singularizing it may be, is not enough, as the mechanical “yes, I think that’s true” uttered after Freud’s identification of the love she has for her employer attests. No effect – in the real – follows from it.

91 This makes it possible to distinguish, from a psychoanalytical point of view, the singularity of utterances from the singularity of utterance. For the increase in singularity to be really effective, both are necessary –a singularity squared, in short, which moreover makes the analytic sessions so intense when the conditions are met for such subjective acuity/density to finally occur. The utterances are then so absolutely condensed in the instant of their effectuation that they are experienced as an act that modifies the individual course of time. This is neither reproducible nor easily describable. With an intensity as mild as Lucy R.’s hysteria, and as much as Freud manages to write some-“thing” about it, this is what seems to take place in the concluding session where his young patient says she now sees “quite clearly”. What she says, she experiences as she says it –in an insight that acts. She is no longer quite the same Lucy R. The cure has worked.

92 In a lesser known passage from The Psychogenesis of a Case of Homosexuality in a Woman (1920), Freud metaphorically addresses this question of the paradoxical double movement of psychoanalytic thought, between the recapture of true utterances and the facilitation of conditions of true utterance. In fact, he places on the side of a simple horizon of work the analyst’s identification of generalities (etiology, diagnosis), including their singularization into a unique life story (uttered by the therapist). This corresponds to phase 1 of the work, which is only a time of preparation – logical, moreover, than chronological:

93

In quite a number of cases, indeed, an analysis falls into two clearly distinguishable phases. In the first, the physician procures from the patient the necessary information, makes him familiar with the premises and postulates of psycho-analysis, and unfolds to him the reconstruction of the genesis of his disorder as deduced from the material brought up in the analysis. [80]

94 As for the actual work, that which is effective, because it acts for the patient, it is then done at the logical level of the uniqueness of true utterance, concerning singular utterances (which emerge here and there, as the treatment progresses):

95

In the second phase the patient himself gets hold of the material put before him; he works on it, recollects what he can of the apparently repressed memories, and tries to repeat the rest as if he were in some way living it over again. In this way he can confirm, supplement, and correct the inferences made by the physician. It is only during this work that he experiences, through overcoming resistances, the inner change aimed at […]. [81]

96 Increasing in singularity, for Freud, is thus not only knowing the singular (in the descriptive, deictic, logical or nominal sense). It is producing it oneself psychically, accompanied by a favorable “other”. It is acting in order to know this singular, with the help of an analyst seeking to know it in order to act.

Conclusion

97 Increasing in singularity in order to act is a particularity specific to psychoanalysis in the field of care, from the nineteenth century to today. In this sense, Freud produces a historical ratchet effect. It is impossible to go back after him. An original tradition of clinical thought is open, although it is caught up in recurring controversies. Today, alongside approaches essentially based on the typical or the generic (of which neuro-cognitive-behavioral therapies – or CBTs—are the major representatives), psychoanalysis remains. Whatever the theoretical currents (Freudian, Lacanian, etc.), they all have one thing in common: centering care practices on the unique operative representations for the subjects.

98 At the end of this journey, two questions arise for us:

• isn’t the extension of the syntagm “clinical thought” to any “face to face with the ‘this’, whatever the field considered, [as soon as there is] a claim to its meticulous knowledge” [82], to the detriment of the precision of its understanding, to take up a classical philosophical distinction? [83] Indeed, “clinical thought”, whether it increases in generality or increases in singularity, is an approach to knowledge historically elaborated in order to act, and not only to know. This need for care – and, even more than that, for its effectiveness –undoubtedly amounts to something in the epistemic shaping that has variously constituted it. By separating “clinical thought” from the treatments it makes possible, would we not be running the risk of uncoupling it from what is its very foundation and allows us to understand it more closely? [84]
• it is undeniable, from another point of view, that clinical thought, before its modern laboratorization, was nourished by philosophy, history, then by literature, and anthropology – that is to say, by a set of knowledge accumulated on singular phenomena having to do with the “human” [85]. As we have shown elsewhere, Freudian psychoanalysis nourishes its clinical case thinking with contributions attributable to the humanities of its time. [86] An essential link therefore exists between traditional clinical thought – a fortiori psychoanalytic –and thought of the singular in a broader sense. Then why not couple, or even identify conceptually, the two, as the argument of the issue suggests?

99 My position, to conclude, is the following: if attention to the singular has an autonomous epistemic tradition (in art, in literature, then in the humanities) cut off from the direct stakes of care, why should we want to subsume this non-clinical tradition under the syntagm of “clinical thought”, at the cost of increasing in generality that risks diluting what it is a question of thinking precisely under the historical term of “clinic”?