HE.S.T.A.F.T.A. - Scientific Society of Mental Health Professionals


  • Marcelo Pakman

Kyriakos Katzourakis paint

_An earlier version of this article was published in Portuguese as “Sentido e Consciência en uma clínica _ da verdade” (2017), Nova Perspectiva Sistêmica, Number 56 (3). Thanks to María Jesús Arrojo Romero for her reflections on the clinical case as well as on different aspects of its theoretical discussion.

If we take these three elements into account [for Marx need, work and enjoyment] we note first that the three together establish a rigorous connection between a real man[1] and a real society and the surrounding material society that is not himself.
(...) The reality of human beings is theorized and linked to transcendence, to a beyond, to what is outside and before them (Jean-Paul Sartre,1961: 3).

Raymond is a fifty years old man consulting because he is “feeling very depressed” and suffering from “intense anxiety” when he is “around people”, to the point of not being able to find a direction in his life, increasingly appearing for him to be rather futile, although without reaching the point of having suicidal ideation or impulses. Ray, as he likes to be called, tells his therapist that his symptoms have greatly increased since his only brother Karl, whom he lives with and whom he attributes suffering from auditory hallucinations since he was an adolescent, attacked him recently with a baseball bat. Fortunately he reports not having had any serious lesions although the episode prompted a police intervention. Ray explains the incident in a very detailed way including his own thoughts and actions during the interaction prior to the attack, that he believes it was triggered because of a confrontation with his brother about his practice of mixing medications prescribed by a psychiatrist with street addictive drugs. Ray believes that this practice exacerbates Karl's “voices” and makes him aggressive. Ray also says he had stopped coming to therapy during a previous consultation with the same therapist several years ago because he was concomitantly seeing, at the same clinic, a psychiatrist he believes did not trust him. Ray gives as an example that the psychiatrist did not seem to believe him when he reported he had been taking a medication prescribed by another professional for attention deficit disorder. Ray had feared that the psychiatrist would tell the therapist about his lack of trust, thus interfering with the therapeutic process and so he had decided to stop attending the clinic. But as a general rule Ray appears evasive when the therapist, trying to understand better this situation as well as others, inquires about it or about responses other people had regarding his behavior. Even more, this consultation happens in the context of a program in which psychotherapists, general medical practitioners, psychiatrists, social workers and other professionals interact frequently among them about the patients who are aware of these interactions. Some of the professionals who have contact with Ray have recently told the therapist that he does not come across as a reliable or trustworthy person, coinciding with and even amplifying a similar sense the therapist has at times during her sessions with Ray, and coherent with what Ray reports that happened during the previous consultation. When Ray appears one day saying that his brother Karl has committed suicide, one of the members of the clinical team finds himself looking at the obituaries in a local newspaper searching for his name.

On another occasion this same member of the team tries to find out if Ray had been, as he says, a member of the faculty of a well known university. All these searches do not reach in general any clear conclusion that would clarify, for those who do not trust him, if Ray is talking about realities, lies or fantasies. When Ray starts reporting that he also hears voices the doubts about his credibility in the clinical team increase even further, while some members of the team say that his explanations about his failure to find jobs in spite of the good qualifications he reports, do not justify for him to be in such a bad social position as he says. His good intellectual capabilities, however, seem to be coherent with the written notes he brings to his therapist after the sessions, showing a wide show range of knowledge and notable literary skills. In other cases there appears at times independent evidence of things he had told the therapist and other members of the clinical team, what makes those who do not find Ray trustworthy or reliable more uncertain of what is going on. Ray has also reported this attitude from people in his social milieu but in most cases he does to seem understand the reasons for him to appear as not being trustworthy or reliable. The therapist asks herself: are we before someone who lies for convenience, who lives a delusion in an alternative reality, who fabulates or who, in spite of the doubts of those who get to know him, is telling the truth. Let us now make a pause regarding Ray’s clinical presentation to take an indirect path in order to explore a classical problem of psychiatry: the distinction between perception and fantasy as it might relate to the problem of hallucination. We will consider then a reading of what Jean Paul Sartre had to say about this and other related matters.

**Perception and Fantasy in ** C **lassical ** P **sychiatry and in ** F reud

In 1845 the French alienist[2]Jean-E tienne Dominique Esquirol, wrote:

A person is said to labor under a hallucination,  or to be a visionary , who has a thorough conviction of the perception of a sensation, when no external object, suited to excite this sensation, has impressed the senses (1965: 92).

Furthermore, the german psychiatrist Emil Kraeppelin would say in 1913:

Esquirol, and after him for practical purposes the majority of researchers, have discriminated between two types of mistaken sensorial perceptions, namely, those in which there is no external source of stimuli: the hallucinations, and those that can only be considered a falsification of a genuine perceptions by means of the additions of the one who lives them: the illusions (Blom, 2009).

Thus Kraeppelin, as the Swiss psychiatrist Eugen Breuler would equally do later on, was expressing to what extent Esquirol had established, with his definition, the lasting tradition reaching to our days that considers hallucinations as  perceptions without an object . Thus defined hallucinations are  pathological forms of perception , assuming perception as the main psychic function in the contact of the  subjective psyche with the objective reality of the surrounding [3].

The psychiatric tradition, working in the shadow of Esquirol and Kraeppelin, gave a disciplinary character to the most ancient and dominant tradition of thought that considers fictions and fantasies against the background of perception and as a subaltern form of the later. The vivid quality of the hallucinatory phenomenon and the importance it takes for the existence of the person experimenting it facilitated the adoption of this psychiatric conception that privileges the perception of the real over the fictitious while it assumed a naively realistic epistemology in which materiality was only the objectification within the consensual exterior space of the things of the world, simply and directly accessible by perceptions of sensory data.

With Sigmund Freud hallucinations acquired an originary role in the primary distinction the infant makes of a world by projecting the displeasure born from the frustration of his/her needs, while he/she reactivates the memory of the object that has satisfied him previously, a process involved in the launching of the dynamics of desire (1985). In so doing, although still caught in comparing hallucinations to perceptions, Freud would promote hallucinations to a category that was not subaltern to perceptions anymore: "I have no doubt that the wishful 4 Although the relation between dreams and hallucinations as well as between hallucinations and certain intoxications had already been indicated before Esquirol. activation will in the first instance produce something similar to a perception - namely, a hallucination” (1950: 362). With this conceptual movement Freud contributed to move away from considering mental images as imitations of the real and of a second class compared to it. Instead of that mimetic conception Freud would stress the productive quality of mental images recognizing them a right to exist on an equal footing than perceptions (Pakman, 2014). However, the tectonic movement made by Freud in the understanding of the psyche was more related to the unconscious than to consciousness and he would maintain that focus on issues related to unconscious processes and the processes involved in the psychoanalytic cure. Thus he was not prone to further develop the problems of perception and fantasy in terms of modes of consciousness and, when he focused on psychoses he was more interested in the incapability of transference as a major obstacle to launch the psychoanalytic cure.

Reading Sartre: Modes of Consciousness

The quality of hallucinations as a pathology of perception and thus of contact with the real would be questioned later on by Jean-Paul Sartre when he focused on the theme of “The image in Psychological Life" (Wilford y Rudrauf, in Sartre, 2012). This dissertation of 1926-27 anticipated later works conceived as a unity, although published separately:  _The Imagination _ (2012) and  _The Imaginary _ (2004b). Sartre, faithful in this regard to Edmund Husserl’s phenomenology (1999) understood human consciousness as being always  _intentional _ to the extent that it was always consciousness of something. The  _first _ consequence of intentionality was that consciousness was always  _transcendent _ because the contents of consciousness were always beyond itself. We could say that consciousness in all its forms or modes always reaches the texture of a world with which it is intertwined, not only in the mode of consciousness operating in perception but also in those of memory, fantasy, the confrontation with works of art as a portrait, photography, caricature, or schematic sketches, among others, all of which Sartre studied in detail. Thus, for Sartre hallucination is not a pathological perception but it belongs fully to the domain of fantasy and, furthermore, it does not imply a lack of, or a distorted, contact with reality. Difficult as it may be for the person experimenting hallucinations to make that doubtless dramatic experience compatible in form and content with the experience of those with whom he/she shares to some degree his/her everyday life, the experience as such does not imply a pathology of perception and a concomitant alteration of the contact with the real. To assume uncritically the long tradition that sees hallucination as a pathology of perception and of the contact with reality goes against the fantasizing or fictionalizing quality of it, the very domain in which Sartre says the hallucinatory experience occurs affirming at the same time that perception and fantasizing are two alternative modes of imagining that exclude each other. What happens is that “there is indeed a hallucinatory act (…) but this act is a pure event that appears suddenly to the patient while perception disappears" (Sartre, 2004b: 150). When the phenomenon occurs "visual or auditory hallucination is accompanied by a provisional collapse of perception" (151). However, although the hallucination is a powerful attractor, perceptive consciousness and the exterior world of consensually perceived objects finally reappear and, at the moment of talking about the event, once reflective consciousness participates, the patient, attempting to integrate the experiences, often locates the hallucinatory event in that perceptual space. This allows Sartre to say:

The patient, speaking of the scene just witnessed, gives it as a part of the surrounding world: ‘I am  here , me who just saw the devil’ easily turns into ‘I just saw the devil  here ’ (151). This location of the hallucination represents a secondary problem, although central to the domain of clinical psychoses, a problem of integration among different types of experience or, as Sartre would put it, of consciousnesses, or rather of modes of consciousness. We will see how this is articulated with the problem of imagination once we abandon the concept of imagination as an individual function of the psyche that produces fictions or fantasies and we understand it instead as a work with images taken as apparitions of the world, wether in the mode of perception, fantasy, exposition to visual art, to theatrical representation, to readings, to rational reflective thinking, etc.

Although Sartre’s conception of hallucination was not incorporated to the mainstream of the psychiatric discipline, as we can see in the persistence, even today, of the dominant idea that a hallucination is a perception without and object that implies an alteration of the contact with reality  in toto , his perspective is a vehicle to a  _second _ quality of intentional consciousness, namely, to  conceive consciousness, in all its forms or modes, to be in principle and at the same time both self-consciousness and consciousness of a world beyond itself, deployed either in a consensual exteriority or in a psychiatric interiority. The alternative spaces of what is consensually “exterior” or psychologically “interior” are not obviously there as a part of a _naive epistemology but they rather appear with the mode of consciousness involved in each case _ _but always intertwined with the texture of the world. In any case there is no pure consciousness _ _in itself. _ Thus,  w ith Sartre,  _transcendence _ and  _self-consciousness _ are always qualities ofconsciousness even when it is not reflective, that is to say, as it is the case in principle before the acquisition of speech. Furthermore, consciousness never stops being so in all those areas of daily functioning in which the immediacy of the world that we inhabit is assumed without any need of reflection, nor of linguistic meanings. For instance, he/she who hallucinates, since there is a selfconsciousness that comes with the experience with no need of reflection, feels a peculiar experience as well as its persecutory or uncanny quality right when it happens, even though he/ she locates the experience in the consensual space of perception when he/she refers it. This is and attempt at making possible for the experiences of hallucination and perception to be composed together when they are in fact alternative ones in sequential terms. This attempt at composing the continuity and sense of experience occurs frequently in other cases, for instance, in the case of oniric consciousness, which is also peculiar when it happens, although we learn, at an early age, to rapidly localize its content retrospectively, upon awaking, within its own irreal[4] space of dreams, helped by the fact that awakening allows to encounter again the circumstances that surround sleeping (the bed or the armchair, the position, the opening of the eyes, etc.) as well as the regularities that rule the consensual everyday space. In this later space we cannot, for instance, walk on thin air without stepping on the ground as it happens in certain dreams.

Consciousness is then always intertwined with objects that appear to us in a world, whether these objects are part of the world of the perceptive mode of consciousness that claims to locate them as stable features in a consensual shared everyday space, or else they are objects of a fantasizing consciousness lived as appearing spontaneously in an irreal non consensual space. In both cases we cannot appropriate ourselves completely of those objects as if we were its creators given that when the objects are real ones they exceed our consciousness offering 5 As Sartre called it, instead of unreal. themselves to other people’s consciousnesses[5], while when they a  re irreal they make themselves present beyond our wills. Thus, Sartre, unlike Husserl, and this would be a  _third _ quality of intentional consciousness, extracts it from the territory of the Ego, which is considered a later addition correlative to a linguistic and reflective process. With this step, Sartre stops understanding fantasy or fictionalizing consciousness on the model of perceptive consciousness, although through a path different than Freud, in order to give it the quality of a type or mode of consciousness, alternative to the mode operative in perceptions. In doing so,  _subjectivity _ becomes wider than the Ego and of the linguistic subject, a constitutive articulation between consciousness and the world although without including an unconscious as in the case of Freud. We can then see a consciousness-world emerging from Sartre's conception.

Primary Non-reflective and Self-referential Consciousness

The primary form of consciousness is from this perspective non reflective but self-referential, because when we are aware we know that we are so, even though the reflective consciousness that appears with speech acquisition is not yet established. This primary consciousness is in principle previous to and remains always in excess of the distinction between external and internal reality and, furthermore and most importantly, it is an experience prior to the emergence of the  _ego _ that we cannot consider then being in control of it. This is an aspect of Sartre's philosophy (1991) that sometimes is not taken into account although it did not escape the attention of Gilles Deleuze who related this non reflective consciousness of Sartre with his own conception of a dimension of sense[6]:

This bestowal of sense (…) may occur only within a transcendental field which would correspond to the conditions posed by Sartre in his decisive article of 1937: an impersonal transcendental field, not having the form of a synthetic personal consciousness or a subjective identity - with the subject, on the contrary, being always constituted (1990: 98-9).

This conception of Sartre of consciousness as transcending the ego aims explicitly at protecting his philosophy from the subjectivism and idealism that ended up affecting Husserl’s phenomenology[7]. Putting the world between parenthesis  in order to focus on pure consciousness, what amounts to the method of the é _poché _ of Husserl’s phenomenology, is for Sartre strictly impossible because consciousness and world are, for us, always inextricably involved with each other. Sartre also criticized the risk of abstraction and concomitant idealism of Heidegger’s philosophy in order to slide toward a philosophy that, as consciousness itself, never detaches from the world. We can only generate the illusion of a consciousness detached from the world when we pay attention exclusively to its content and we thus generate abstract concepts that can become metaphysical. At the same time, we cannot purify the world from a consciousness because there are objects of the world present themselves to many consciousnesses, thus becoming consensual. With his early works on imagination together with his  _Sketch for a Theory of Emotions _ (1962), The  _Transcendence of the Ego _ (1991) and some other articles (1939, 1948), Sartre's conception of consciousness, integrating critically both Husserl and Heidegger, started the development that would culminate in 1945 with  Being and Nothingness , his treatise on existential phenomenology in which he elaborated a philosophy of  _freedom _ not divorced from reality in spite of his sophisticated view of the role of the negative and nothingness on the steps of Hegel. Thus, Sartre placed himself on the path of a phenomenology that, according to Gilles Deleuze (2006), had been inaugurated by Immanuel Kant as long as we understand it, following the most common reading of it, as the abandonment of the dichotomy, attributed to Plato[8] (1991) between  essence , as the ultimate reality of being transcendent to the Idea, and  existence , as an impure and everyday form of that ideal _. _ This reading of Plato’s dichotomy remained within the conception of image as a fictional appearance opposed to either the transcendent reality of the Ideas, or else to the material reality accessible empirically trough sensory data. Inside this dichotomy image as imitation. a degraded form of being, would still survive when fantasy or fiction started to be conceived as a creation without a mimetic aim, thus becoming naturalized as a common sense concept. It was Kant, with his critique of transcendental essences, who stopped conceiving images as appearances, either mimetic or creative, to conceive them instead as the apparitions of reality itself, although this movement did not become dominant neither in the philosophical tradition nor in society at large. Sartre joined the sliding of emphasis from the perception of the real of being towards the possibilities opened by fantasy and fiction that had been already present in Freud and was supported also by the theoreticians of twentieth century Hans-George Gadamer (1976) and Paul Ricoeur (1976). In the XXth. century the linguistic turn within a radical postmodern form of radical culturalism did not stop at promoting fantasy to be a full mode of consciousness with a quality on an equal footing to perception, as Sartre had done, but, however, it enthroned reality as a simulacrum of fiction reverting the classical primacy of empirical sensory data over images understood as mere imitations (Pakman, 2011). However. Sartre was not part of the postmodern movement and the privilege it gave to the domain of the possible which made the real to regress infinitely, entering in a collusion with the linguistic turn of philosophy and humans sciences. This movement tried to found itself in the oeuvre of Michel Foucault, Jacques Derrida y Jean Baudrillard, among others, despite the alarms sounded by these authors themselves against that type of idealistic readings (Pakman, 2014). Sartre, besides his critical debt to Hegel and Kant took also Renée Descartes (2000) as a starting point, going beyond both materialistic and idealistic readings of the three most famous Latin words of the formula that works as a cypher of his philosophy:  _Cogito ergo sum. If _ cogito , from the verb  cogitare , is translated as I  _think _ or I  know , and  sum , from the verb  esse , as I  _am _ or I  exist , the word  _ergo, _ translated in general ambiguously as  _therefore _ or as  _then, _ seems to give a cue for the type of reading implied in that formula. An idealistic reading would say:  _I _ think, therefore I am. Existence would then be in this case a consequence that follows from the _fact that I think. Knowledge or thinking become then the origin of being. _ If we add, as it happened after the successful incorporation of linguistics to the linguistic turn in contemporary thinking, the idea that thinking and knowing happen in language, we find what Alain Badiou has qualified as a linguist idealism (Badiou y Žižek, 2009). A materialistic reading, instead, would take us to read the Cartesian dictum as  I think and, therefore, I existThinking shows that I exist and existence would be the origin of thought and of knowledge because if it did not exist it could neither know nor think . But Sartre, although he considers that being is the necessary condition of thinking and of knowledge and of course of human action as well, does not see it as a sufficient condition that would take us to consider the content of thought as a consequence immanent to being, since in that case it would eliminate freedom on behalf of an absolute determination, as he claimed, for instance, in his conference  _What is subjectivity? _ At the Gramsci Institute of the Italian Communist Party in Rome in 1961 (2016). At the same time, Sartre’s position is at odds with idealism, either classical, or linguistic which considers thought and knowledge as linguistic constructions creating what they name. Thus, Sartre said that "to provide a philosophical foundation for realism" is what "I have tried to do all my life, in other words, how to give man both his autonomy and his reality among real objects, avoiding idealism without lapsing into a mechanistic materialism" (1969: 36-37). The conceptual movement of Sartre, perhaps the last of classical philosophers[9], aim at a consolidation of phenomenology in realistic 10 and materialistic terms and at a characterization of human existence in which consciousness is inevitably intertwined with the world and its determinations not only without renouncing freedom but also being a protagonist of it. Sartre would locate his third position, in his early work, in the tradition of  existentialism and then he tried to integrate it in a coherent unity with Marxism in his late work (2006, 2004a, 1968). A fundamental consequence of his position is,  first , that thought and knowledge are not limited to reflection because primary non reflective consciousness, prior to speech and in excess of it when this is already present is, in any case, a  _pre-predicative knowledge. _ That is to say,  _it _ 10 For this reason qualified by Foucault as a nineteenth century philosopher attributing to him, maybe unjustly, an immediate and acritical adhesion to the subject as agent, when in fact Sartre articulated a conception of subjectivity that exceeded language, and that it was a product of his research on consciousness that tended to be critical also of the psychoanalytic unconscious, although it went through different periods.  _happens in the dimension of being more than in that of knowing supported on the _ _epistemological subject-object dichotomy. _ And,  second , this immediate pre-predicative consciousness implies a  _non reflective self-consciousness _ that does not take itself as an object of analytic knowledge .

An Intermediate Dimension of Sense

We can read this conception of Sartre of a non reflective primary consciousness that implies being conscious of itself without being objectified, as being in a path that would include thinkers like Gilles Deleuze and Jean-Luc Nancy (2012, 2008, 1997). Both developed a concept of  _sense _ (as different from linguistic meaning) as well as of  _presence _ (as different from representation). In the case of Sartre he was interested in describing modes of consciousness, a third position as we saw in terms of the dichotomy between being in itself and reflective consciousness, position that he describes a primary non reflective consciousness. Deleuze, while recognizing in a note that Sartre's “idea of an ‘impersonal or pre-personal’ transcendental field, producing the I and the Ego, is of great importance” (1990: 14 n 5: 343-344), critically signaled that Sartre was still caught in a field of consciousness as unified, unlike his own philosophy that took flight from this idea of a primary unity to assume unequivocally a virtual field of immanent forces, made of singular events and prior to the constitution of an actual world of objects already stratified in everyday space and time (Dif and Rep, 1969). The dimension of  _sense _ that Nancy explores is, like Deleuze’s, not centered either anymore upon consciousness but it is also, as in Sartre, the product of a search for a third position between a mechanistically determined and inanimate world and the dimension of meaning, a dichotomy heir of the one between body and soul.  _Sense _ appears also as the primary incorporeally oriented element immanent to the materials bodies of the world. This  dimension of sense , that I took in a reading of Nancy as part of my development of a critical-poetic position in psychotherapy, cannot be identified with sensoriality, nor with meaning, in spite of being very often considered a synonym of this last term, as if they were alternative terms for the same concept. Sense, in the reading I am making is instead the earliest dimension, closely involved with the corporeal sensory motor integrations that we can find at the root of what will later, with speech acquisition, be fully developed as meaning. Early on, the observation of infants in the context of the dyad they are part of together with whoever takes care of them (Winnicott, 1982) makes visible that, before entering into language and reflection, as an objectified knowledge of our human world by a cognizant subject, we can distinguish what I have called a  _sensory-motor ecology of the lap _ (2014, 2011) within which  _subjetivity is a vivid _ _experience of the consciousness-world as we can read in Sartre’s philosophy. _ This  _sense of the _ _world _ is not a reflective or linguistic understanding of what there is or there exists but it isinstead central for the early competencies studied by Jean Piaget (1971), and it amounts to the primary mode of non-reflective and immediate human experience within which we develop as human beings. Thus, we cannot identify sense with the empirical world of sensory data, nor with the dimension of meanings which is a later acquisition rooted in that primary and immediate sense of the world, that is to say, the condition of possibility of meaning making as a fully developed phenomenon. This early sensory motor ecology is at work when, for instance, a baby is learning in action that not everything heard can be seen, that not everything visible can be touched and brought to the mouth, or that not everything that is brought to the mouth can be eaten, etc., all part of the many explorations happening in the context of the lap as ecological medium, a micro-community inhabited by an adult speaking caretaker and a by definition non speaking infant, in which sense develops attached yet to the body and prior to the possible abstraction of contents that later on fully developed speech will be capable of. If meaning is quite adequate for analytic thinking, sense, looking instead imprecise, is the background against which meaning will become possible. My critical-poetic position for psychotherapy (Pakman, 2011, 2014, 2018) a reading of the dimension of sense elaborated by Nancy, takes on Kant’s conception of image, which was still for him linked to a transcendental subject, although it brings it to be an ontology of worlds or of realities that come to existence discontinuously making themselves  _present _ without assuming any transcendent place of origin as an ultimate condition of its being, either divine or metaphysical, ideal or material, subjective or objective, conscious or unconscious. In fully incorporating Kant’s conception of image as apparition of reality both perception and fantasy become modes of that apparition, while in Sartre they are modes of consciousness because  _any _ consciousness implies the apparition of a world . For Nancy sense is not "the ordinary presence of the real" (2005: 11) that sensory data offer to our perception, even when the conception of perception is a complex one, as in scientific empiricism. We would say that  _images, in all its _ _forms or modes, are pulses of reality brought forward by themselves while a distinction is created _ between themselves and a background in the very act that brings them to presence . And images always have a  _vivid texture _ because they are always beyond a pure consciousness, in the sense of Sartre (Pakman 2014: 120). Every image is an apparition of a  _sense that is sense in itself and that _ makes sense as a birth to presence of the real of a world . Sartre’s conception of a  _non-reflective _ _primary consciousness, prior to the existence of an ego and an identity, is a concept with _ _qualities compatible with this dimension of sense that Nancy considers undetachable from the _ _fragmentary worlds we inhabit instead of an addition to a unified world.  _ It is within the dyad infant-caretaker that an existential ontology is established at the same time than the primary ethical orientations understood as a pulsation  _toward a better life as _ an endless search . This dimension of sense that always remains present although often as a potentiality hidden by the meanings of fully developed language, implies that our ontologies always have an inclination to ascribe value to our world, even before the entrance into language with speech acquisition. The sense of the world is not to be fully identified with Sartre’s non reflective consciousness that belongs however to its territory. Sense is wider in scope besides being logically prior to reflective consciousness and meaning and sometimes it operates fully outside consciousness as a part of an immanent embodiment in our world. Besides, sense isnever lacking or negative and oscillates between the quality that life is worth living it and the onethat life is futile.

Therapy of Sense and Truth

Let us go back now to Ray’s clinical situation in his interactions with his therapist and the clinical team she belongs to. The situation brought by Ray is very complex. Someone may know that he/she is lying but others may admire him without seeing him as a lier or may justify him without feeling he/she is fooling them, while others may know that he/she is fooling them assuming he/she has good reasons to do it. Another person may not be seen as trustworthy because he/she appears to be lying and he/she may realize he is seen that way but without seeing him/herself as someone who lied or tricked people or gave reasons for that untrustworthiness.

This is what appeared to happen with Ray. There was some relation between what Ray was reporting and the reactions of those in touch with him and listening his reports, on one side, and an empirical reality, on the other side. The facts he was talking about  _existed _ in a certain way that was not unknowable for him or for others, even if they were not known by everybody or even recognized by himself as being lies, fictions or facts. What we can assert is that  _the sense of not _ _being before someone who was trustworthy was an existential truth, even if Ray did not see the _ reasons for these feelings many people experienced about him . If all those who saw him as untrustworthy or unreliable always showed a lack of confidence toward everybody, it could be that this sense was not related to him, but even if unjustified it would still be an existential problem of sense for Ray because there was people not trusting him anyway and he was suffering the consequences of this. Sometimes this reached others who, having with more or less of a connection with him, in principle trusted him at least in some areas of his life, but felt compromised by the lack of confidence of others toward him. The therapist looked for a way to bring to the sessions that sense of untrustworthiness experienced by others that was impregnating the atmosphere when being together with him and that we can consider an existential truth. For this truth to be linked with an empirical truth she should have found a fact either hidden or that could be seen as a lie. But if she embarked to work predominantly in that direction, his job would become one of a detective. However, this empirical aspect was important and the therapist reasonably refused to adopt the position of ignoring “external reality” to take care only on “internal reality” without paying any interest to empirical reality, as many therapists either do or they say that they do. The therapist privileged in his situation a third position, namely, to take care of an existential truth that was, however, intimately linked to empirical truths in the everyday world. The mandate the therapist imposed on herself was, regarding Ray: “you are saying the truth or you are not but in any case you do not appear as a reliable or trustworthy person as you present to me and others beyond the way you represent yourself, what I will not analyze as a private detective in terms of its empirical certainty nor I will ignore on behalf of something transcendent because we are not here building a metaphysics”. The focus of the therapist in assuming this was the  _sense _ of the experiential truth of the untrustworthiness generated by being with Ray on many people, including at times the therapist herself, as related to the empirical truth he reported. In other words: the issue was how the empirical truth and the experiential truth could be  put together and integrated as possible , that is to say, how they could be sustained together, which is a problem at the level of what I have called the  _work of imagination as one of integration. _ Karl, Ray’s brother existed or did not exist in everyday consensual reality and, if he existed, he had died or he had not. Ray could not find a job because he had been or he had not been rejected, and he had worked or he had not in the university he was naming, and if he did, he had completed it or he had not for the reasons he alleged or for other reasons. But to ask for or to force a “confession” about the facts of what had happened to him could somehow ruined the fact of taking care of the existential truth that he did not appear to be reliable or trustworthy, what was probably affecting all his everyday life. Historical truth was configured by both the empirical truth and the existential truth, but playing the role of a detective could undermine the role of the therapist, while maintaining this role as a mere interpreter would deny that what was to be interpreted was somehow also linked to empirical reality.

The therapist, resisting to fall in any of those roles inconvenient to her task gave priority to the  _dimension of sense _ that Ray was not reliable or trustworthy that made for a singular atmosphere for him and others, as he himself recognized. Maintaining a subtle balance the therapist avoided to run the risk of not protecting Ray's dignity, answering, for instance, when he asked: "Do you believe I am telling the truth?” by saying: “I do not know Ray, but I don't work as a confessor. What reasons could have those who say they do not trust you, for not doing it?” And if this resulted equally threatening to Ray, she would ask him, for instance: “In what way could it affect you or has already affected your life the fact that they do not trust or rely on you or even, as it is the case for me or for others, not being sure about the reality of something's you say?” Once Ray felt sure that she was not asking for confessions from him, the therapist could, little by little, start discussing with him how that untrustworthiness, that he started to see progressively as something that he was at least contributing to, was permanently affecting his relationships and dooming his efforts. He then started to conceive his social and work defeats, his lack of friends and his love life in light of the truth of sense that was impregnating the minicommunities he was part of in his everyday life. One time the therapist, advancing in the same direction, asked him: "What do you think Ray you are better for, to generate untrustworthiness towards you, or to improve that trustworthiness that others show toward you?” Ray told her, very affected: “I do not know how to improve it… I am a prisoner of this bad reputation, that is why I leave at times”. The therapist asked him: “And where do you go Ray when you leave?” He said: “Where nobody doubts about me” and laughed sadly knowing that that place was an empty one and a Ray inhabit it in solitude."

Bad faith

Based on the previous considerations we can think that there is for Ray and those who interact with him impregnated by a sense of untrustworthiness a possibility other than lying, fabulating, not being convincing or being mad. According to that possibility, if we put ourselves in the domain of sense, Ray would also be, in any of those cases, in what Sartre would called a situation of  bad faith . For Sartre every human being tends to slide toward bad faith since we are beings divided between two ways of being: the being-in-itself of what is already completed, of things and objects, on one side, and the being-for-itself of consciousness, always moving orienting itself in a world that transcends it, on the other side. This scission imposes that, as Sartre never stops reminding us, we are not [in our consciousness] what we are [objectified] and we are [objectified as beings-in-itself] what we are not [in our consciousness for-itself, founded on the possibility of the negation of what is-in-itself] (2013: 95-125). As an expression of this scission between two ways of being we act frequently in bad faith,  _as if we were not more than _ _what we are. _ The manifestations of this bad faith are many but they always represent an escape from freedom to the extent that we treat ourselves and others as if either we were completely determined to act the way we do or as if our freedom were pure and absolute, something possible only if we were a transparent consciousness located outside the material world. Because being what we already are is to be either already determined as objects, either totally free as incorporeal abstractions, diaphanous, insubstantial, in both cases without the  _texture _ of the world, partly determined being and partly open becoming. And this constitutive duplicity is endlessly negotiated as, for instance, Ray did, as a partly coherent life at the price of presenting itself before others in a constant atmosphere of uncertainty, doubt and mistrust. This presentation of Ray, from our critical-poetic position, as someone subjected to dominant micropolitical forces but open to poetic discontinuities of change, we cannot totally confront only from a moral point of view as if it were an intentional deceit, nor we can deny it. We need a good faith effort that can expose and legitimate his duplicity presenting us as actors of a consciousness/world in a dimension of sense that can never be a unity according to moral principles unless we live in an ideal abstract world.

As therapists, we can also act in bad faith when, for instance, we slide toward the search of evidences. But if we do not do that and we seek refuge in fantasy with the argument that our job is to care only for either psychological realities or social constructed phenomena, depending on our theoretical persuasions, we assume not only a position that is not the one we maintain in our everyday life to move around the world but we also bypass the domain of sense when someone like Ray presents himself before others who feel uncertain about the quality, real or irreal, of some aspects of his life. In doing so we do not have the chance to help him to make possible together, to composibilize[11] those experiences with ot  _12 _ hers aspects of his everyday life.

This impossibility may take him to a scission in his life between orders of experience that he appear unable to be put together, to integrate as we always do, in relation to others and to ourselves. Madness cannot be asserted in Ray’s situation in which the attribution of reality or fantasy is not clear. We usually insist in either of those paths as if there were an essential dichotomy between the empirical and the interpretive as only possibilities. This dichotomy leads  us to scotomize the level of immediacy of consciousness-world, an aspect of the dimension of sense. But in the case of Ray the therapist was guided clinically by the sense of the experience she was living with him, which was marked, as in other relationships, by  _uncertainty _ but also included that he was suffering because the way he appeared before others was often neither trustworthy nor reliable. Given that people could not elicit if his experience was true or false this extended to his very suffering that people could not say if it was true or false either (Sartre, 2013). There seemed to be a matter of the existential ontological truth of sense at play and not only one of empirical epistemological truth. Those who search truth in empirical data tend to use it as a criterion of pathology or cure while those who search for it in the world of meaning would focus on what they consider either psychological reality or social construction, in both cases bypassing the dimension of sense we described. But the core or a clinic of truth is not to be found in the epistemological truth of correspondence between things and intellect but: first, in the existential truth of sense of the world, or rather of the world as sense always linked to historical truth that needs to be substracted as a specter coming back from the cloud of signs surrounding us, understood mostly as processes of meaning; second, in the integration of this level of sense with the empirical level and the hermeneutical level of meaning, making them to be possible together although not necessarily in a perfectly unified whole.

Dominant micropolitics and a poetics of sense

In everyday life situations the sense of the world prior to all the dichotomies between objective and subjective, material and ideal, becomes constantly captured by  _dominant _ _micropolitics _ that create repetitive scripts (Foucault, 2000, 1994, 1985; Pakman, 2014, 2011).

The fight to convince people that Ray is a trustworthy and reliable person and the concomitant search of many therapists to force a distinction of truth from falseness, or of reality from fantasy, with the help of empirical data or, instead, the denial of anything that is not the inner psyche, could all be expressions of a dominant micropolítics of the therapeutic field. This micropolitics grew, in many countries, in the context of the commodification of the mental health field and its capture by the health insurance companies following the principles of neoliberal market economy and the correlative to the advance of the biology of neurotransmitters and the primacy of psychopharmacology. At the same time postmodern tendencies in psychotherapy set up a pseudo-resistance to those trends diluting the materiality of a world turned into simulacra while a version of those social and cultural sutured (Badiou, 2006) to meaning as the locus of reality and change was promoted. This postmodern pseudo-rebellion, apparently opposed to a neuroscientific empiricism was in fact convenient for a mental health field that insurance companies either took control of and administered, or help format even in countries were mental health organization was not in their hands. Thus, they were the central forces in the rebuilding of a mental health field built on bio-behavioral bases, which included patients now renamed as clients or consumers and professionals educated in the dichotomy empirical-hermeneutical in which even a space for freedom was redesigned functioning as “his majesty’s opposition.” Meanwhile the walls of private practices could not stop this dominant micropolítical process whose apparatuses of power/knowledge shaped the new professional subjects implementing these practices while they were circularly shaped by them (Foucault, 2000, 1996, 1985; Pakman, 2011).

But real  _resistances _ to those dominant micropolitics can also be deployed working on the dimension of  _sense _ that is neither reduced to the empirical data, not to an exclusively hermeneutics of interpretation. In many cases this work at the level of sense, as in the case of the therapist working with Ray, allows for  _poetic _ events to happen, in the sense of the term  _poiesis _ as an arrival or birth to presence or apparitions as existent (Chateau 2014; Goyet 2014). In the case of Ray the apparition of an isolated man living in a cloud of mistrust maintained inadvertently while searching for a socially respectable position, neither a victim, nor a trickster. Through poetic events what comes to the fore brings back the primary  _poiesis _ in which the world appears or is born to presence, which is both logically and chronologically previous to the separation between reality and fantasy, and between epistemological subject and object. The world does not stop appearing as images, either perceptive or fictitious, that is to say, as sense or, in Sartre’s terms, as consciousness intertwined with a world. This is the dimension of  _subjectivity _ that we engage with as therapists. S _ubjectivity _ understood as a place of freedom before the historical determinations, without ignoring them. This subjectivity cannot be reduced to the epistemological subject of the reflective knowledge on the objects of the world, nor to the subject of the linguistics of Saussure, either the ego of the enunciated sentences, or the subject of enunciation or the unconscious. These two attitudes are supported by the adoption of models that become part of our professional identity while they go through historical developments becoming more or less dominant, as they are now those related to scientific empiricism, fostered by the advances in neurosciences, and those related to the linguistic turn of the past century that, although seriously questioned by many thinkers and practitioners in the last twenty years, is still traversing a late dominance in the fields of psychology, psychotherapy and family therapy. In the dimension of sense, it is very important to remember that everything that is inscribed in a system of meanings also and at the same time, exscribes, as Nancy puts it: The thing itself, “existence”, the “real” — which  _is _ only exscribed and whose  _being _ alone is what's at stake in inscription. In inscribing signification, we exscribe the presence of what withdraws from all signification, being itself (life, passion, substance …). The being of existence can be presented: it presents itself when exscribed (Nancy, 1988: 64).

In light of a  _clinic of truth _ we can take the responsibility, the risk, and the courage implied by the fact of telling the truth, the  _Parrhēsia _ that was the central focus of Foucault’s last classes (2012).  _To tell the truth _ is not easy, but it not something to deny as impossible either. In many cases it is not something that we can simply affirm or state, nor sustain univocally. It requires, instead, from us, as split and limited beings, a permanent work that could open, day in and day out, to that which does not cease to appear and that needs to be substracted, as real and true, from the cloud of signs that we inhabit, which are accompanied by moral orders of principle rooted in bad faith structures. This is why truth often requires a work of imagination that attempts at sustaining events that bring existential types of truths with other aspects of our lives, including empirical and universal truths. This process of imagination oscillates between the subject positions we usually occupy and the wider subjectivity of a consciousness/world in a process of becoming that appears endlessly although discontinuously. There is the truth of the immediate non reflective consciousness, only accessible to me and including a self-consciousness in the sense that I know what I am experiencing as a quality with a general inclination, even when I do not know the various meanings it can have. There is also a truth of observation of what is considered as an object by a subject of knowledge and this is an empirical truth discontinuous with existential truth. Sartre would speak of “the truth for me” and “the truth for others”. The truth of observation or “from the outside” can be correlated with the truth “from the inside” that Francisco Varela would talk about. Epistemological truth does not have to be always an universal truth. In the case of Ray his sense of not being trustworthy to others which others did in fact experienced. So, the truth of sense emerges often in a shared atmosphere beyond subject and objects, in the realm of the being together prior to that distinction. Sense as an inner experience it is also about something that exceeds oneself according to our physical limits. The truth of observation does not have to be universal. The testimony someone gives could be either existential or empirical, but in the last case it can always be questioned in terms of its content because it happens at the level of observation. Universal truth is an empirical type resulting form reflective rational thinking. Its contents is immanent with effects on all of us regardless of our reflective consciousness and not necessarily linked to a direct existential experience of it. However, there is and indirect empirical observation that works as a starting point of a search that ends up at times in the universal truth, even if temporarily valid, and at times in existential truths, like the experience of falling of objects in the case of the universal law of gravity, even if this one can be re formulated, expanded and theoretically falsified by another universal explication, wider in scope (Popper, 1992). In the case of historical truth we have both types of testimony: of the existential truths that we are only conscious ourselves although they are not necessarily limited to individuals, as we saw in the case of Ray; and of empirical truths of what one can observe about events including others or oneself taken as an other, direct or indirect, and sometimes acquiring an universal quality.

These are the reasons why  _psychotherapy as a clinic of truth _ has to show what brakes not only the materialistic determinations that would make of us only what we already are, but also the idealization of seeing ourselves as absolute and voluntaristic owners of our destiny, exploring if and how to make possible together the empirical and the hermeneutical, on one side, with the intermediate level of  sense , on the other. This work of the imagination as composibility puts together at once events and everyday life, the extraordinary with the ordinary, the deviancy with the usual life rhythm, the impulse to a better life with moral principles, the emergence of the discontinuous novelty with the continuity of acquired meanings, events with dominant micropolitics to be changed. It is this work of imagination what makes for a human existence in which world and consciousness live the endless adventure of freedom which is not, to start with, signaled by reflective and linguistic knowledge linked to fully developed meanings, but by an onto-ethics of sense. What matters is if we are capable of making composible our life with others in the presence of what ceaselessly appears to our consciousnesses in the pulsations of the sense of the world, including the consequences of our actions. An ethics of sense questions every moral that is part of the situations in which that singularity of sense appears and becomes pertinent. Without a clinic of truth embodying an onto-ethics we risk surrendering to what Sartre used to call a  will _to ignorance _ that “postulates that nothing  _is _ except for what we create", projecting a world inwhich: "1. What we don't know doesn't exist; 2. What we know exists only insofar as we knowit; 3. We choose at will to know or not to know [when in fact we know many things we did not decided nor wanted to know including that peculiar way of knowing of the non reflective consciousness]" (1992: 52). The onto-ethics of a clinic of truth. instead, remains open to the  _poetic events _ without ignoring what is irreparable in personal and social history and managing to substract ourselves from the regulated life of dominant micropolitics, thus dynamizing its abstract moral orders of principle in light of the endless search for a better life, an always vacillating life worth living (Pakman, 2018).


[1] Sartre, as it was usual by then, used the masculine generic to speak about human beings.

[2] As psychiatrists were called then stressing the psychic alienation of the patients, now called clients or consumers since the neoliberal market stepped into the the mental health services lending it also its language (Pakman, 2011).

[3] Although the relation between dreams and hallucinations as well as between hallucinations and certain intoxications had already been indicated before Esquirol.

[4] As Sartre called it, instead of unreal.

[5] Even if we do not consider the relations among them as mind independent objects as realists philosophers do in different ways.

[6] In this aspect similar to the conception of sense of Jean Luc Nancy that we will consider later.

[7] Ronald Aronson has argued that Husserl gave to perception a complexity that Sartre did not recognize (1980). Sartre believed that Husserl aligned himself with a “nutritional” conception of perception that conceived it as if subjectivity to swallowed the world. Husserl had recognized that perception was not a mere passive impression because he added active aspects to the process, as in his classic example of a cube that is perceived as such although it never exposes more than three sides to our perspective. These adumbrations, sensual perspectives of aspects of the perceived object, although integrated in a phenomena can object were however distinct from the eidos or essence of the object perceived which happened intellectually and a priori. Husserls remained an idealist from this point of view (De Landa and Harman, 2017).

[8] For other critical readings Plato’s Idea was not a pure abstraction but, on the contrary, implied an embodied form. It was then a precursor of readings closer to the one I am presenting here.

[9] For this reason qualified by Foucault as a nineteenth century philosopher attributing to him, maybe unjustly, an immediate and acritical adhesion to the subject as agent, when in fact Sartre articulated a conception of subjectivity that exceeded language, and that it was a product of his research on consciousness that tended to be critical also of the psychoanalytic unconscious, although it went through different periods.

[10] Categories of Hegel.

[11] A neologism naming an important concept in the work of Leibniz and of Spinoza, later taken and studied by Deleuze (2006).


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ARTICLE 3/ ISSUE 15, October 2019

Some reflections on becoming a therapist; What remains and what changes over the years

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