It is inevitable that the question of medication divides therapists at this point as it reflects the fundamental divided consciousness of our era - the division between mind/body or spirit/matter. Certain people in this group are convinced that to heal (which comes from the root of whole) one must accept something beyond materialism.
Medication "cures" nothing of the psyche (being, soul, subject) - as all psychiatric studies have to admit - it temporarily substitutes biochemically induced experiences. Pharmaceutical medicine is made from a base common to coal tar (think of the oil industry) and by adding certain side chains chemists are able to manufacture certain biochemical responses in the body - which can even reverberate to "trick" the mind or body. But no actual change occurs at the higher organizing level of self or bodymind - no cure. That is why they have to be administered forever - unless a higher cure comes about through other means - psychotherapy or the individual's innate healing capacity.
Thankfully the resilient human usually heals himself despite the intrusion of biochemicals which interrupt the immune system's natural process, but they leave toxic residues of increasing danger. Iatrogenic (medically-induced) illness is the number one cause of death now. True it may be useful to use these material medicines in emergency situations to stabilize murderous/suicidal possibilities, organ failure, or pain which prevents sleep and healing for example, but few understand the costs - most important of which is robbing the individual psyche and somatic immune system of assimilating and transforming life experience. Although this is a growing perspective held by phenomenological, existential, psychoanalytic, and spiritual approaches, it still comprises the minority in today's institutions.
The bodymind is a homeostatic system. The more pain blockers are administered, the more pain is produced by the body in response, causing habituation, addiction, and increased doses. Withdrawal requires the body to readjust - not just to getting along without it but now to the fact that it has more of the very problem it took the medicine to cure. This has been demonstrated in recent studies of anti-depressants but covered up and/or not comprehended. The side effects of this type of medicine are seen as unwanted by-products when they are actually inevitable effects of isolated mechanistic tampering with a homoeostatic system (the same way orthodontic teeth straightening creates TMJ jaw dysfunction.)
The question is not "medicine or not" but what kind of medicine and how. There are forms of medicine (naturopathic, homeopathic) which effect changes at the higher level subtly while allowing the conscious mind or self to assimilate these changes and thus work with the psychotherapeutic process of true transformation. Even this has limitations. If therapeutic techniques or ideologies - or even the ego of the therapist - come to fill in for the self of the patient they are not much better than drugs. Psychotherapy is not inherently good:
A lot of psychotherapy is worthless if not damaging and the patient often knows it is not helping.
A lot of times the psychotherapy cannot break through certain patterns without other interventions, but again pharmaceuticals and surgery are not the only alternative.
And sometimes it just takes time and patience - something this culture does not respect.
The ideal trajectory would be to use the least amount of coercive therapist-induced medical intervention necessary to produce temporary stabilization and containment and break patterns, while providing the non-judgmental ethical-aesthetic space for the deconstruction and reconstruction of new subjectivities in line with the drive, desire, soul, spirit, destiny (take your pick) of the individual. Of course this makes it clear that the socio-economic problems of this culture cannot be separated from questions of psychic and somatic healing.
Pain and illness are messages and opportunities for healing a bodymind out of balance. Can we respond to this message through contact, sympathy, mutual aid, and courage, or will we repress the message with drugs and therapies until it returns with a vengeance. Have we forgotten this simple and profound rediscovery of Freud.
Sigmund Freud "Beyond the Pleasure Principle"
Carl Jung "The Psychology of the Transference"
George Cangilhem "The Normal and the Pathological"
Hans Selye "The Stress of Life"
Samuel Hahnemann "Organon of Medicine"
George Vithoulkas "A New Model for Health and Disease"
Hans Reckeweg "Homotoxicology"
Jean Elmiger "Rediscovering Real Medicine"
Wilhelm Reich "Discovery of the Orgone"
John Upledger "Your Inner Physician and You"
Ron Dunselman "In Place of the Self: How Drugs Work"
LFC Mees "Blessed by Illness"
Soul Murder and Iatrogenesis
The investigation of the truth surrounding the Screber case serves as a model for a revelation about a cultural norm elaborated by Aulagnier's work surrounding the concept of "the violence of interpretation." We must be at pains to elaborate the "facts" by listening to Schreber's own words concerning his experience rather than the interpretations imposed on him by Flechsig, Freud and others. At the same time we must be careful not to allow the facts to simplistically support a ubiquitous "real" physical abuse of Schreber and other children put forward by Niederland, Schatzman, Shengold and others too quickly. This would be to make the same mistake as Masson and others concerning the supposed cover up by Freud of real sexual abuse. The point - made clear by Laplanche - is that seduction, abuse, or trauma is inevitable, whether real or imagined, and that the psychic apparatus in its ideal state - supported by certain familial, interpersonal, and/or therapeutic interaction traverses a journey of encounters which elaborate the birth of subjectivity and the expansion of the "I." The soul murder is not in the original abusive event but in the violence of interpretation that murders the psyche's ability to assimilate and transform the event for itself. In this sense our whole culture and especially the medical model continues to conspire in soul murder. This is why it is not surprising to find that "soul murder" was an actual medico-legal term from Schreber's time refering to iatrogenesis - doctor-induced illness. The radical event of Freudian analysis was to reverse this process and listen to the patient, yet even most therapists and analysts still regress to the violence of interpretation through there transference to the theories and authorities which protect them.
Lacan's work maps this journey of the subject between drive and the Other, and Aulagnier demonstrates how the total eclipse of the drive by the intrusion of the Other prevents the elaboration of the subject in psychosis. This violence by which the Other interprets the experience of the child is simply less complete in cases of neurosis or normality. In neurosis we thus speak of a divided subjectivity (between drive and Other) at odds with the currently accepted norm, whereas in any given cultural norm a certain moral and physiological "truth" dictates the object relations among its participants. Freud posed this issue in "Civilization and its Discontents" and Lacan again ran up against this problem of the dualistic impasse of either neurotic subjection to the symbolic order or psychotic foreclosure of it, before resolving it in his later work on the "sinthome."
Becoming-Woman
If Schreber is the most cited patient in medical history, then perhaps it is because he is a kind of "Imitation of Christ" for our times. If we listen to his words he says his problem is a nervous illness. Perhaps Schreber's crisis is not the total foreclosure of the symbolic but an increasingly problematic confrontation with it which manifests as various symptoms - first as a nervous exhaustion and depression and later as so-called "hallucinations." In many respects we could take Schreber at his word and recognize that his problem is more neurotic than psychotic. (Increasing practice with our times may show us how much this is a continuum rather than separate categories.) The refusal to be recognized as a master in his newest professional victory as well as the failure to become an actual father may have given rise to a kind of flight into hysteria with all the associated neurasthenic qualities in addition to the position of being a woman to God.
We could then pose a different scenario in which Schreber, after repeated confrontations with his father who spoke of the necessity to "break the will of the child at any cost," after continuing to compete with other men in his chosen profession of judge, finally fails to be able to shoulder this burden of becoming master and judge of a high court. Unrecognized in his new town and unable to succeed in fathering children with his wife, he has a final breakdown in which he becomes one to be cared for. In terms of the dualistic model of psychosis or neurosis/normality this is certainly a failure of the name of the father. But is it possible that Schreber will turn his symptom into that of an enjoyment of what Deleuze and Guattari call "becoming-woman" - into an exploration of another way of being - not judge but judged, not master but servant, not carer but cared-for, not God but "a woman."
In this approach, rather than assuming a symptom to be a lack of what should be, we assume the symptom to be a creation - albeit unconscious - of what needs to come to be. By listening to it and mapping it, we allow it to take its course and either fall by the wayside to make room for another becoming in the birth of the subject ,or see that it is in fact the birth of the subject in which it becomes consciously assumed and lived - communicated to others through semiotic means which deconstruct and reconstruct the rigid symbolic. This process which has been well described by Bergson, Bataille, Bion, and Eigen as the function of the mystic has so far operated in our times in the everyday life of the artist more than in that of the analyst and analysand.
Fear, Mysticism, and Analysis
This poses a new model for analysis, in which we really let go of the "violence of interpretation" in favor of a kind of psychoanalytic mysticism partially mapped out by Lacan, Bion, Eigen, and Phillips. He who accompanies the other on a journey of subjectivity along with its terrors and ecstasies requires courage and experience more than clever knowledge in the application of techniques.
Hallucination and Perception
Finally the relation between self and other, inside and outside, dreams, thoughts, hallucinations, perceptions, and sensations depends more on how we come to collectively construct reality out of the real. What has been at stake for so long is a micropolitics of desiring production. Who controls reality. Is it possible to collectively create in a model which honors both the relational aesthetic and the individual ethic of sovereignty. Let us find out.
"The problem of anxiety is a nodal point at which the most various and important questions converge, a riddle whose solution would be bound to throw a flood of light on our whole mental existence." (Freud)
Your raising the question of anxiety is sure to provoke anxiety in those who prefer to refer to diagnostic category-objects. Far from being objectless (or due to object-loss), it was Lacan who reminded us that anxiety arises in the presence of the object of desire. This is confusing unless we understand that for Lacan the object is always the fantasy that emerges at the moment of (its) loss. The object is a transversal linkage that commemorates a relation, so that transitional, partial, part, and self objects (not to mention clothes, cars, and books) are only so many remains of an overwhelming real jouissance (ecstasy-enjoyment) from which we all come. Strategies differ among individuals as to how to cope with the fundamental "bipolar" relation of isolation/fusion and its concomitant anxiety which you refer to through so many clinicians, and in psychosis the anxiety and the strategies are extreme.
Anxiety is so much the experience of the truth of humanity (as well as the core of symptoms) that we should not forget that these issues were negotiated in other cultures through rituals which we no longer possess:
"The anxiety of the neurotic individual is the same as that of the saint. The neurotic, the saint are engaged in the same battle. Their blood flows from similar wounds. But the first one gasps and the other one gives.
What chance demands of men: friendship.
But anxiety? shameful old hag at whom one refuses even to spit!" (Bataille)
For Bataille anxiety is what remains as we hold back our isolation even in the presence of our desire to connect - the solution being communication or communion, for "death can only strike the isolated being" whereas "anxiety communicated turns into glory." Clinically this would call on us to move further away from an object-oriented interpretation-based approach toward a relational analytic communion sketched out by Lacan and Bion in their later work.
Roberto Harari "Lacan's Seminar on Anxiety"
Georges Bataille "Inner Experience"
Sigmund Freud "Introductory Lectures"
Recent discussion of your style has alerted us to something we should pay more attention to: that form and substance are often inseparable in expression. If we insist that the child or the psychotic speak in our language is this helpful. Can we not be humble in the reception of the other's message (the Judaic ethic of Levinas) or suspend anxiety while deciphering the incomprehensible (as an ethnographer). The lover, the poet, the patient often speak to break through our own resistance - in order to achieve what...
"Paradoxically, intimacy is violence, for it does not respect the isolated ego" (Georges Bataille)
"[My approach] does not conceive of the primal relation between the physiological and the psychic apparatus as one of mutual dependency but as one of functional identity with simultaneous antithesis .... The fact that the two mutually influence one another, however, is far less important for the comprehension of the psychophysical relation than everything which supports the view of their functional identity."
Wilhelm Reich
While the modern west gropes its way toward an integral holism, we should recognize that there are already models of medicine/psychiatry in which body is mind and vice-versa. For thousands of years, Taoist Chinese Medicine, Buddhist Tibetan Medicine, and Ayurvedic Indian medicine have practiced - and continue to practice - an integral bodymind medicine in which "psychotherapeutic" events have direct bodily results, and medicinal formulas and practices have direct results on changing "mind" or "spirit".
The most important aspect of this work though is the context in which this medicine is practiced. Rather than an ethics of symptom suppression, the clinical relationship is itself the transformative containing environment in which substances and other interventions provoke embracing, assimilating, and releasing of physical and psychic traumas consciously.
The reason there are no western psychiatric (or physiological) pharmaceuticals without side effects is because of the context in which they are used. An understanding of systems theory and the Arndt-Schulz law will demonstrate that every intervention made to the complex homeostatic human bodymind system will provoke various reactions, and Hans Reckeweg has proven that even aspirin and antibiotics impregnate toxic substances (like a kind of repressed trauma) which then continue to compromise the body's immune system. Like a repetition compulsion these symptoms seek to return and be assimilated but we pummel them with more toxic drugs instead.
Freud stumbled on to this empirically (clinically) when he saw his patients' symptoms return or become other worse symptoms with both medicine (pharmaceuticals) and psychotherapy (hypnosis). While he made it possible in the west to conceive of the power of mind over body, even more importantly, he reversed the politics of medicine to a listening transformative process rather than an active enforcement of the power of the physician to change the symptom or the patient in his own image (the image of the current logos).
Reich extended this work to develop a truly psychoanalytic, holistic bodymind medicine and ended up rediscovering many of the principals and practices of Oriental Medicine without knowing it (as well as the homeopathic, osteopathic, and naturopathic medical practices which were simultaneously being marginalized by political-economic mechanisms).
All of the pieces of the puzzle are now available to us if we would only begin to put them together. While I do in my practice, it remains difficult to help many given the institutional structures which maintain the current system. It is not enough to understand the importance of a psychological or spiritual precedence, one must develop a truly spiritual medicine, psychiatry, and science.
Reckeweg "Homotoxicology"
Reich "Discovery of the Orgone II: The Cancer Biopathy"