The American Journal of Psychoanalysis, 2008, 00, (1–9)
© 2008 Association for the Advancement of Psychoanalysis 0002-9548/08 $30.00
www.palgrave-journals.com/ajp.
Aleksandar Dimitrijevic
The paper reviews and discusses Groddeck`s conception of illness. I first argue that Groddeck was a late Romanticist as much as he was a “wild” psychoanalyst. Then I use Groddeck`s scattered formulations regarding definition, foundation, and meaning of illness in order to articulate them in the form of more explicit scientific statements. Finally, I suggest that Groddeck`s theory of illness is fundamentally different from current medical conceptions, which, nevertheless, does not make our dialogue with him either less useful or indeed less necessary. It is through an investigation of Groddeck`s therapeutic attitude and the spirit of his work that psychoanalysis and medicine can build foundations of bold, innovative, and healing future.
Key Words: Groddeck; theory of illness; romantic medicine; the It; mutuality.
DOI: 10.1057/ajp.2008.1
INTRODUCTION
It is sometimes forgotten that Sophocles’ “Oedipus Rex” has illness as one of its major topics. At the very opening of the tragedy, the city of Thebes is in great trouble because of the plague. And what might seem unusual to the contemporary reader is that the whole community is engaged in the process of finding out the meaning of illness and removing the cause. At the end of the tragedy, Oedipus is considered the cause and he himself admits his guilt and asks to be punished rightfully so that the order can be restored.
Much closer to our time, there is something analogous to illness in Shakespeare’s “Hamlet” At the end of the first act, Marcellus says that “something is rotten in the state of Denmark” (I.iv.92). This could be interpreted as a metaphor for a disorder, for an illness that has plagued the whole kingdom. In that case, the difference between this play and “Oedipus Rex” is striking. It is only Hamlet, and to a smaller extent Horatio along with two or three of their friends, who are aware of the rottenness. Hamlet is the only one who searches for the meaning and causes of the bout of illness in the kingdom he should have inherited. And at the end of the play, Hamlet supposedly reinstates meaning and health, paying with his life for the victory over the rottenness that he did not provoke.
And in the time witnessed by Georg Groddeck, many important writers have also tried to describe how their contemporaries experienced the phenomenon of illness. I think that one excellent illustration is Thomas Mann’s “Death in Venice”. In this novel, Gustav von Aschenbach suspects that a dangerous infection is threatening Venice and starts the quest for truth. But this is 1910, and Venice officials are lying to Aschenbach that there is no epidemic and for one obvious reason: admitting that there is a danger, they would lose tourists and income. Unsurprisingly, Aschenbach dies alone and without help, in a state of mental as well as physical breakdown.
This is, I believe, one important aspect of the context of Groddeck`s efforts to treat his patients and -unwillingly, as it were- to define the concepts of treatment and illness themselves. For Groddeck was constantly doing what 20th century medicine tried to avoid at all costs. While at the beginning of the 20th century the medical curriculum - that is, founding medicine in natural sciences, with the allopathic, individualistic, and secular approach - was introduced (see Turner, 2001), Groddeck was a child of 19th century education. Unlike Freud, however, who was strongly influenced by natural sciences and their determinism, reductionism, and mechanicism, Groddeck was impressed by Romanticism. This influence on Groddeck is so strong that Henri Ellenberger claimed that “Groddeck`s description of the id reflected, to an extreme degree, the old Romantic concept of an irrational unconscious” (1970, p. 844; italics mine). The Romantics lived in a world of passionate love and creative labor, their uttermost hope was that the world of emotions will eventually rule over the world of reason. They emphasized the notions of man’s relationship with nature, nature’s and soul’s hidden foundation (unstructured, unconscious material that expresses itself through poetry, dreams, and mental illness): “human life was regarded as a participation in a kind of cosmic movement within nature” (ibid., p. 203). Nature contained a “life force” and had a “healing power” (ibid., pp. 207 – 208) (1).
Another important influence on Groddeck came from early psychoanalytic theory of illness. Freud is usually said to have initiated the second revolution in the history of psychiatry with his claims that symptoms have meanings, and they will recede after their meanings are understood and interpreted to a patient. Strongly backed by their clinical results and Jung ’s association technique, early psychoanalysts -more or less explicitly- emphasized the hermeneutic approach and opposed the medical model of disease. Groddeck almost independently discovered some of the basic psychoanalytic concepts and procedures. Since his first letter to Freud, he provided exciting illustrations of the effect of interpretation on symptoms of various illnesses and it seems that Freud labeled him a psychoanalyst without any hesitation (Groddeck and Freud, 1977, p. 36). But I think that an extremely important similarity can also be found between Groddeck and Carl Gustav Jung, who, in Martin Bergmann’s words, was another “Romantic, a follower of Nietzsche” (2004, p. 15). The direction of the influence is, unfortunately, still unexamined and I cannot tell whether Groddeck ever met Jung and whether the two ever read each other’s books. Still, in my opinion, Groddeck`s theory of illness is closer to Jung’s than to any other psychoanalytic notion of that time. Although context, definitions, and interpretations may differ, the “keywords” used by Groddeck and Jung are strikingly similar: rejection of the rule of the conscious; importance of symbols created in the unconscious; “purposivism” undifferentiated life energy; vital forces; wholeness.
Groddeck`s theory of illness was the most developed one in the early history of psychoanalysis. This may sound strange, because Groddeck claimed never to have formed a system, but, in one way or another, all of his writings touch on the subject of illness and his theory of illness can easily be deduced from his theory of the unconscious.
Firstly, Groddeck thought that the unconscious is the basic and the strongest force in human life and that our identity and behavior are simply expressive manifestations of this force. He thought that the unconscious, or the It as he called it, was initiating everything that we claim to be our intentions or decisions. We are like toys in the It’s hands, because “man is lived by the It” (1979, p. 11) and “everything is directed by this unknown It” (1949, p. 210; emphasis in the original). Groddeck writes that the It exists before the formation of the brain (quoted in Schacht, 1977, p. 16) and perhaps even before conception (Groddeck, 1917, p. 114). He ascribes such power to it that he asserts: “… God is in us, we are God, the It is God, an omnipotent God” (1920, p. 152); or “The It […] shapes man ’s nose and hand as well as his thoughts and emotions” (Groddeck and Freud,1977, p. 33).
Groddeck`s second very important attitude was that there was no real difference between the psyche and the soma (1979, p. 119), between the sexes or age (1979, p. 19), or between health and illness. Groddeck thought that all of these are to be considered merely expressions of the It and that “the use of analysis is a question of efficacy, and not one of the field of illness. It is completely unimportant for the use of psychoanalysis whether the [It] has used for its expression the organic or the psychic or the nervous system …” (after Grossman and Grossman, 1965, p. 159). He thought of his work as a mere application of psychoanalysis to organic disease (1949, p. 209). And when we say that Groddeck was the first to systematically explore the unconscious motivation in organic illness (Groddeck, 1977 in Schacht, 1977, p. 1; Groddeck and Freud, 1977, p. 32), the term “unconscious” should not be understood to mean “psychological”. Groddeck wrote that “[…] there is no psychological cause for physical illness. The unconscious is neither psyche nor physis” (Groddeck, 1917, p. 128) and that “the distinction between body and mind is only verbal and not essential, that body and mind are one unit, that they contain an It, a force which lives us while we believe we are living” (Groddeck and Freud, 1977, pp. 32 – 33).
Next, Groddeck thought that there was only the It, that it had an “absolute power” (Groddeck, 1925, p. 199) and that it united everything that we perceive as human. Both consciousness and the I are merely tools of the It (in Durrell, 1979, p. xiv; Groddeck and Freud, 1977, p. 38). Groddeck thought that illness too is simply a manifestation and creation of the It. The illness is one further form of the It’s expressive behavior, but a vital one (1979, p. 232), since it is a symbolic representation of inner conflict (1979, p. 101). In his opinion, when the It perceives that it should send us a message and we are unable to understand it for some time, there is no other means for the It to communicate with us but to make us ill. This happens, Groddeck writes, on two occasions: the It says either that (1) it will now restrict independence it once provided to the organism, or (2) it will not take any further responsibility for its creation -the now ill person (1925, p. 199). So we see that illness does not come from without (1979, p. 235), but it is a purposive internal process.
Groddeck`s understanding of therapy was also original. To begin with, he believed that a diagnosis did not mean anything, that each instance of a disease was different (Grossman and Grossman, 1965, pp. 137 – 138), and that we should be approaching the patient, not the disease. More importantly, he thought that the It decided what to do with the prescribed treatment and that the It used environment both for provoking illness onset and for inducing a recovery (in Schacht, 1977, p. 20). Echoing what he learnt from his teacher Ernst Schweninger -to “regard the physician as a mere catalyst, setting curative process in motion” (Grossman and Grossman, 1965, p. 36). Groddeck thought that the healing agent was neither the doctor, nor the medication, but the It: “life itself is the main analyst, and what we doctors contribute is not more than a pathetic presumption. We are instruments without a will, used by life for some forever inscrutable ends” (Ferenczi and Groddeck, 2002, p. 34).
In his earlier writings, Groddeck held that the role of the therapist was to decipher messages from the It and to interpret them to the patient. In this way, the It would no longer require the illness to express itself, and the reason for the illness would disappear. He also followed Freud conceptions a bit too closely when in 1917 he wrote that “the essential thing, the transference itself, is a reaction process in the patient, and for the most part it lies outside the doctor’s influence” (p. 125). In the later stages of his work, Groddeck`s clinical approach changed considerably and its significance lies in being a predecessor of what we now term the interpersonal or relational psychoanalysis. Groddeck was open to the almost revolutionary acceptance of maternal aspects of transference and the mutuality and disclosure in therapeutic work (see Rudnytsky, 2002, Chapter 8). Groddeck has several times written about healing processes in which the It of his patients had healed his It. In his 1926 paper “Treatment” he generalized that “the physician treats the patient and is simultaneously treated by the patient” (p. 225). For this reason, the therapist should always be grateful to his / her patients for receiving free treatment. And in order to benefit from it, he/she must “wage against his own vanity and the megalomania fed by the public, by the facts of life and by the self-adulation innate in man”(p. 227). In accord with his general theory, Groddeck maintained that the therapist was never responsible for therapeutic advancement, but that he was always to be blamed even for a minute strain in the relationship with the patient. Sounding more like a contemporary of ours than of Freud’s, he claimed that “what matters then is to find out what kind of mistake it was and to discuss it honestly with the patient; without any embarrassment or attempt at apology” (p. 226).
But what happened with these notions that Groddeck proposed in his works later? Are they now something else than a curious chapter in the history of medicine?.
Although Groddeck`s works were written in as widely read a language as German, and some of them translated into English more than half of a century ago, I think that their influence is almost unnoticeable. As far as my insight into medical curriculum goes, Groddeck is now known solely as the originator of the psychosomatic approach - with details about this or any other aspect of his work obscure and unexplained. And while it becomes more and more frequent that, for instance, dermatologists accept the possibility that their patients’ problems are induced by emotional instability and disorganization, psychiatrists become more and more likely to ascribe their patients ’ disorders to biological causes. As Gail Hornstein has recently noted in her biography of Frieda Fromm-Reichmann, it is strange that of all medical practitioners, it is psychiatrists who are least impressed by the powers of mind (2004, p. 379; see also Grossman and Grossman,1965, p. 140). Thus, the division between the psyche and the soma is implicitly present in all major psychiatric textbooks and classifications, and contemporary mainstream psychiatry embraces, just as it has always done, exactly those options that Groddeck explicitly rejected (1979, p. 243): symptomatic treatment and external causation versus causal treatment and internal causation.
It is not only that Groddeck`s books seem to be less widely read and discussed, but also the trends in contemporary psychiatry have been completely opposite to what Groddeck advocated. There is, however, one further important fact in this comparison: Questions are no longer asked that Groddeck would have liked to see asked. There are only a few authors who discus the topic of meaning of illness at this moment. Major psychiatry textbooks do not devote more than a couple of pages to this problem. Those who do discuss illness, or “disorder” as we have called it for the last quarter of a century, do so through a lens completely strange to Groddeck.
I shall make a brief description of the most frequently quoted contemporary definition of mental disorder, in order to show how different these approaches are. I shall summarize and say that Jerome C. Wakefield (1992) defines mental disorder as a harmful dysfunction. In this definition, the term dysfunction designates the problem caused by the inability of a mental function selected during the evolution of our species to perform what it was selected for. “Harmful” on the other hand, is a value term that should imply that a particular culture considers some dysfunctions as harmful and some as harmless. Only in the case that a specific phenomenon is proved to be dysfunctional and is at the same time considered harmful, we can think of it as a mental disorder.
It is not only that we cannot see any of the topics important to Groddeck either in Wakefield’s definition or in any of its possible implications. Georg Groddeck held a position peculiar even for the psychoanalytic camp. For a time, there was a controversy about the way he performed his therapies and even “bizarre results” were mentioned (Alexander and Szasz, quoted in Grossman and Grossman, 1965, p. 160). With the ascent of interpersonal and relational schools of psychoanalysis, the situation has changed. Groddeck is now considered one of the pioneers of these approaches and there is a growing interest in his work among psychoanalysts. However, although this is true in regard to the later stages of Groddeck`s analytic technique, his understanding of the foundations and meaning of illness can be considered to stand on different positions. In this part of his work, Groddeck is strongly interested in internal factors, and sometimes even overemphasizes the role of symbols (see, for instance, 1979, p. 49), so he might prove to be quite different from contemporary postmodern, constructivist, and relational approaches.
Still, I think that it is arguable whether this should be considered a sign of some basic flaw in Groddeck`s thinking. The direction of his thinking goes opposite to the current trends. This, however, does not mean that in one of their frequent historic turns medicine and psychiatry will not try to become more than “technology applied to human body” and psychoanalysis will not try to put equal emphasis on relations and forces. But regardless of possible future outcomes, I think that despite his tendency to make overgeneralizations, and his being deeply rooted in Romanticism of the previous centuries, Groddeck is still the author with whom we can and should make constructive dialogues even outside his undisputed contribution to our therapeutic technique. Perhaps not all of his answers will be our answers, but Groddeck is certainly someone who delivers the most important questions and reminds us of issues we tend to forget in the age of fragmentation, mass media, and the quest for instantaneous answers.
Furthermore, Groddeck can teach us what to do with these questions even if we cannot answer them. One level of this is in the image of Groddeck as an unlikely theorist, like, for instance, when he writes that “our task is less that of thinking up valid theories than of finding working hypotheses that are of use in treatment” (1917, p. 128). Precisely those working hypotheses and a form of mentorship, so to say, from his patients have led to his most important insights. In several cases, which he has described in detail, Groddeck had not only learned from his patients, and gained from these contacts personally, but also has influenced the development of psychoanalysis in what seems to be the only way possible: learning from severely disturbed persons.
Another level is reflected in Ernst Simmel’s tribute to Groddeck: “For in his heart of hearts it is not psychoanalysis which interests him, whether as a movement or as a body of thought, but men, and in particular the man afflicted by disease” (in Grossman and Grossman, 1965, p. 166). I read this as a statement of the most important side of Groddeck`s wildness: his extraordinary courage to try therapeutic procedures that were many times risky for his reputation; his constant readiness to experiment, to work with patients in ways challenging and frightening for other therapists; his capability to work without being supported, encouraged, and tranquilized by the ideological side of psychoanalysis.
And finally, it may even turn out that Groddeck was fundamentally right. In our negligence to check his answers to the questions that should lay in the foundations of medicine, we have never disproved them. We have just been behaving as if they were not there. Therefore, the most creative and beneficial development might prove to be the appearance of new and many analysts whose wildness would be of Groddeck`s type.
Referencias:
Bergmann, M. S. (Ed.) (2004). Understanding dissidence and controversy in the history of psychoanalysis. New York: Other Press.
Durrell, L. (1979). Introduction. In G. Groddeck (1977) (Ed.), The book of the it. Original edition 1923. V. M. E. Collins (Trans) (pp. v – xxiv). London: Vision Press Limited.
Ellenberger, H. F. (1970). The discovery of the unconscious. The history and evolution of dynamic psychiatry. New York: Basic Books. Ferenczi, S. & Groddeck, G. (2002). The correspondence. C. Fortune (Ed.), J. Cohen, E. Petersdorff, N. Ruebsaat (Trans.). London: Open Gate Press.
Groddeck, G. (1917). Psychic conditioning and the psychoanalytic treatment of organic disorders. In G. Groddeck (1977) (Ed.), The meaning of illness: Selected psychoanalytic writings including his correspondence with Sigmund Freud. L. Schacht (Ed.), G. Mander (Trans.) (pp. 109 – 131). London: Maresfield Library, 1988.
Groddeck, G. (1920). On the It. In G. Groddeck (1977) (Ed.), The meaning of illness: Selected psychoanalytic writings including his correspondence with Sigmund Freud. L. Schacht (Ed.). G. Mander (Trans.), (pp. 132 – 157). London: Maresfield Library, 1988.
Groddeck, G. (1925). The meaning of illness. In G. Groddeck (1977) (Ed.), The meaning of illness: Selected psychoanalytic writings including his correspondence with Sigmund Freud. L. Schacht (Ed.). G. Mander (Trans.) (pp. 197 – 202). London: Maresfield Library, 1988.
Groddeck, G. (1926). Treatment. In G. Groddeck (1977) (Ed.), The meaning of illness: Selected psychoanalytic writings including his correspondence with Sigmund Freud. L. Schacht (Ed.). G. Mander (Trans.) (pp. 222 – 234). London: Maresfield Library, 1988.
Groddeck, G. (1949). Exploring the unconscious. V. M. E. Collins (Trans.). London: Vision Press, 1989.
Groddeck, G. (1977). The meaning of illness: Selected psychoanalytic writings including his correspondence with Sigmund Freud. L. Schacht (Ed.). G. Mander (Trans.). London: Maresfield Library, 1988.
Groddeck, G. (1979). The book of the It. Original edition 1923. V. M. E. Collins (Trans.). London: Vision Press Limited.
Groddeck, G. & Freud, S. (1977). Correspondence. In G. Groddeck (1977) (Ed.), The meaning of illness: Selected psychoanalytic writings including his correspondence with Sigmund Freud. L. Schacht (Ed.). G. Mander (Trans.) (pp. 31 – 108). London: Maresfield Library, 1988.
Grossman, C. M. & Grossman, S. (1965). The wild analyst: The life and work of Georg Groddeck. New York: Braziller.
Hornstein, G. A. (2004). To redeem one person is to redeem the world. The life of Frieda Fromm-Reichmann. New York: The Free Press.
Rudnytsky, P. L. (2002). Reading psychoanalysis. Freud, Rank, Ferenczi, Groddeck. Ithaca & London: CornellUniversity Press.
Schacht, L. (1977). Introduction. In G. Groddeck (1977) (Ed.), The meaning of illness: Selected psychoanalytic writings including his correspondence with Sigmund Freud. L. Schacht (Ed.). G. Mander (Trans.) (pp. 1 – 30). London: Maresfield Library, 1988.
Turner, B. S. (2001). The history of the changing concepts of health and illness: Outline of a general model of illness categories. In G. L. Albrecht, R. Fitzpatrick and S. C. Scrimshaw (Eds.), Social studies in health and medicine (pp. 9 – 22). London: Sage Publications.
Wakefield, J. C. (1992). The concept of mental disorder: On the boundary between biological facts and social values. American Psychologist, 47 (3), 373 – 388.
The American Journal of Psychoanalysis, 2008, 00, (1–9)
© 2008 Association for the Advancement of Psychoanalysis 0002-9548/08 $30.00
www.palgrave-journals.com/ajp
Journal: AJP Disk used Despatch Date: Ed: PRASAD
Article: 3350052 Article Type: Pages: 1-9 Col Figs: Op: KGU
Paper presented at the Clinical Sandor Ferenczi Conference, August 2 – 6, 2006, Baden-Baden, Germany.
Address correspondence to Aleksandar Dimitrijevic, MA, Faculty of Philosophy, Department of Psychology, University of Belgrade, Filozofski Fakultet, È ika Ljubina 18-20, Belgrade 11 000, Serbia; e-mail: adimitrij@ptt.yu
Nota:
1.- It also seems possible that in his notion of the It Groddeck builds on the pre-Socratic conceptions of physis, and that this is another, and maybe even more important aspect of Nietzsche’s influence on him (see Groddeck, 1949, p. 210) than borrowing the term “das Es”.
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