Seminars at Sainte-Anne - Year 1

Singular subject or social subject: who falls ill and who needs to be treated?

Illness concerns each and every one of us. It affects both singular and social identity. Indeed, illness affects the subject not only in the uniqueness of his or her existence but also in the social group to which he or she belongs. The caretaker’s task is to envisage a restoration of these two sides of the same subject when the illness has often affected them in different ways.

The aim of this presentation is to reflect on the issues of care in this twofold recovery.

Phenomenology traditionally recognizes a dual concept of identity. On the one hand, it isolates the singular identity that refers to the essence of the self and reflects what constitutes the unique part within each of us. On the other hand, it also distinguishes the identity which is based on a societal foundation. Just as the singular identity is contemporary to the life of the subject who experiences it, so the social identity is shaped from pre-existing characteristics. The constraints of language, culture, customs, representations and references imposed by the socius on the individual require that he or she gradually absorb them through “porosity”. Although not intrinsic to the self, this imposed social identity ends up becoming the self, especially since the subject is recognized as such by the members of the group.

When the subject is ill, this duality and dialectic are called into question.

The self is experienced in the present. According to phenomenology, this experience is inseparable from the nature of time. Indeed, if we consider that a living system is evolutionary, we must accept that it can only be evolutionary if it is inscribed in time. Time thus comes first. Any change in the subject’s psyche is therefore the possessor and expresses, because it is the expression of it, the properties of time.

The present and the duration, continuity and discontinuity, are all characteristics of time that permeate the experience of somatic and psychic life. The immediate experience of the self, both intimate and shared during the healing process, is therefore endowed with the properties of the present.

At once unique, complete and full, self-contained and irreversible because it occurs only once, the present is also elusive and almost non-existent because it is virtually enclosed between a past that has just come to an end and a future that is just beginning. Thus, the self that is experienced and shared in the moment is both complete (as if in full consciousness) and elusive. The psychic identity, the child of time like all living things, is thus dual. It is a straight line made of a succession of aligned contiguous points/instants, like an accumulation of discontinuities. This attribute makes it susceptible to change at any moment, especially as regards beliefs and goals. But identity is also the child of an elusive present, embedded in the flow of time, with no identifiable beginning or end. As such, identity is elusive. As we can see, contiguity and continuity together constitute the subject’s psychic identity.

These qualities require the subject to perpetually recreate the self, his “being in the world”. Past, present and the tension of desire are interwoven to constitute a dynamic metaphor of the unity of the self.

The intrusion of disease disrupts this integrative work. The horizon, previously transcendental, becomes bounded by the finitude revealed by the disease. Urgent adjustments are needed. They can take various forms, for example those of sideration (freezing time for a moment that would last forever) or hypomania (cramming in extra moments of life between two moments that move too quickly towards the end). This existential and dynamic barycentre is at play in the healing experience.

As we have seen, for the phenomenologist, identity is also made up of societal invariables that are gradually assimilated as so many building blocks with which the subject creates his identity. Patient status, the social discourse on illness and treatment, the health care institutions, the cultural determinants concerning death or the causalities of illness will all contribute to the construction of a new patient identity. Psychosis, depression, serotonin, antipsychotics, societal references to states of nature suddenly intrude into the subject’s inner vocabulary. Social conventions and the current state of knowledge, these terms and statuses will progressively occupy the subject’s identity. But does he or she recognize himself or herself in them? What is sometimes called denial or poor adherence on the part of the patient is perhaps the reflection of this discrepancy between the lived experience of the self and the social designation of the sick self. Nevertheless, collective identity is required for the reconstruction of the patient. It is the embodiment of an implicit set of norms and caring practices, which are important elements in the creation of the social bond and the recognition of a legitimate patient’s existence.

Illness thus doubly modifies identity, both the intimate, instantaneous and continuous identity of the experience of illness, and the collective identity conferred by the status of patient.

Faced with this double recasting caused by the illness, the therapist tries to conceptualise the dynamics of adjustment, their strengths and their shortcomings in order to assist the indispensable work of mental malleability that the illness imposes. Internal and individual work by the subject, as well as the work of the social group to integrate the illness and the patient as a part of the world. Although this work goes beyond the therapist’s own capabilities, his responsibility – which he shares with the patient’s – is to ensure that the meeting that takes place in the moment is as constructive as possible for the patient’s life project. During his physical meeting with the patient, the therapist provides a kind of prosthesis of the present, a crossroads, singular and collective but shared, from which a narrative framework of the subject can be constructed for himself, and between the subject and the others, the world.

In this approach, the patient’s body and the therapist’s body, as well as the social body, are to some extent the essential parts of this work of elaboration. The dialectical subject between object body and subject body is constantly knitting together a possible state of the self. At once tool and subject, vehicle of the being in the world, object of the disease, the body is an essential actor of the psychological work.

The relationship to the body, the models of the body conceived by the therapist must be in harmony with those experienced by the patient. The biological and psychological models of the disease are multiple, non-homogeneous and interconnected. The therapist’s understanding and the circumstances in which these models are used, especially those challenges faced by the patient, determine the theoretical choices made by the caregivers and therefore the therapeutic decisions made. This explains the differences in the assessment of the same clinical situation by two therapists. An ethics of theoretical and practical choices is therefore key, allowing the therapist to determine the most relevant standard of care for the patient given the circumstances in which he or she finds himself or herself.

In the same way, the patient is faced with the need to understand and express his or her singular experience. To do so, he must use representations, words and systems that are intelligible to himself but also to others. The patient, like the caregiver, thus uses collective determinants to describe his singular experience.

Medical symptoms and self-experience, the use of societal constants, and unique decision making are permanently intertwined in both patients and caregivers. The objectification of the disorder and the implementation of care based on subjective representations of the self and the disease intersect and form the basis of the history of care. While both the caregiver’s formal knowledge and the patient’s experiential knowledge are essential, they are not sufficient to establish care. The latter is part of a shared project and a shared encounter in a territory based on trust and an acute awareness of an eminently contextual ethics of action. Kindness, concern, a desire for co-construction and innovation are the other essential ingredients for the care of the subject, both singular and societal. In this context, new models for understanding the underlying factors in disease and care, other actors such as family members, and other public care strategies are needed. The meeting of these factors remains ineluctable.

Philippe Nuss
Psychiatrist, Hospital Practitioner, University Department of Psychiatry and Medical Psychology. Saint-Antoine Hospital, Paris
Sorbonne University, Inserm UMR_S 938, Saint-Antoine Research Centre, Paris, France.