Skin in Psychoanalysis

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Skin in Psychoanalysis is an important theoretical contribution, revising several authors starting with Freud in whose writing we can now discover multiple direct or indirect references to the skin. It adopts a decidedly complex point of view regarding the skin here: the skin as source, the skin as object, the skin as protection and as a way of entrance, as contact and as contagion, the skin 'for two' within the relationship with the mother, the skin as envelope and as support, as a shell presented as 'second skin', as demarcation of individuality, as a place of inscription of non-verbal memories, toxic envelops and so on. Also, being the result of more than fifteen years of work with dermatologists and patients with skin diseases, psoriasis in particular, the book can be seen as a serious proposal for interdisciplinary work between dermatologists and psychoanalysts.'The hospital is a place where both tragedies and miracles occur, where many people go to heal but many others go in search for punishment. It is a place where patients cannot, and should not, question treatment, because doing that will be interpreted as being "on the side" of disease.'This is perhaps the reason why Jorge Ulnik has devoted his entire professional life to psychosomatics, trying to understand diseases as singular experiences which are inscribed as chapters in the vital history of people. By chance, or due to some unconscious determination, his interest in psychosomatics led him to the dermatology ward, where doctors asked for interconsultations with greater frequency. And in the same way as the skin is the erogenous zone par excellence, it is also the entrance and the exit door for many emotions and situations which mark us.'- From the Introduction

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1 The skin in the work of Freud

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Although Freud expressly refers to the skin in several passages throughout his work, and even goes so far as to grant it the status of “erotogenic zone par excellence”, referring to the skin in the Freudian work is not exclusively to speak of the skin as an organ and its eroticism, but also to speak about the functions and diseases of the skin, the drives which are originated in it, the action of touching and its consequences, as well as contact in general and its relationship with contagion, the relationship between the skin and identity, and lastly, about the Ego and the functions of boundary, surface, protection and perception. With this in mind, the references to the skin and its functions will be arranged into the following sections:

•  The skin as an erotogenic zone

•  The skin and its functions with regard to the unconscious

•  The touching drive and the skin as the source and object of the drive

•  Contact as a general idea. Contact and contagion

•  The skin as a cortical layer: its functions of boundary, surface, protection and perception

 

2 Didier Anzieu’s Ego-skin

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Didier Anzieu starts with two basic assumptions. The first is that psychic life has sensitive qualities as a basis because “every psychic function develops on the basis of a physical function the operation of which surpasses the mental area”1 (Anzieu, 1987a, p. 107). The second is that “the tactile sense is the foundation, on condition that it is forbidden at the necessary time” (Anzieu, 1987a) (p. 152).

It is according to these basic assumptions that, in Anzieu’s opinion, the psychic apparatus develops, taking as its starting point a basis provided by physical experiences of a biological nature in which the skin plays a fundamental role. These experiences, which are of both external and internal nature, will then be re-signified through the interaction with the agent who produces these stimuli (generally the mother) and later, on acquiring the symbolic capacity, will be represented again in an abstract form, becoming fantasies, symbols and thoughts.

By means of the physical stimuli, the skin can provide the psychic apparatus with the representations which constitute the Ego as well as its main functions. In this way, a construction of the self that Anzieu calls “Ego-skin” can be developed, one that carries out a series of fundamental functions in order to provide the Ego with the capacity for reception, perception, protection, cohesion, support, integration of sensations, identity and energy. Taking the Ego-skin as a starting point, an Ego capable of thinking and of representing can be developed, an Ego that he calls the thinking-Ego.

 

3 Contributions by other psychoanalysts and psychiatrists to the subject of skin and psychoanalysis

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As has been seen in the work of Freud, allusions to the skin within psychoanalytic theory are manifold, and there are also several authors who have written about this subject within post-Freudian psychoanalysis. In addition, the skin is usually an “entrance door” for all those who become involved in psychosomatic problems, and when it is time to offer clinical examples, eczema (Schur, 1955; Pichon-Riviere, 1971), psoriasis (Korovsky, 1978), hives (McDougall, 1989) and other dermatoses are usually included. To mention all the authors would be an enormous task which is beyond the scope of this work. In consequence, I shall make reference to some authors whose ideas will be mentioned or discussed in the remaining chapters of this book, or to those authors who have developed subjects the intrinsic importance of which justifies their inclusion.

In “La piel como órgano de expresión” [The skin as an organ of expression] (1978), Roberto Fernández makes reference to Freud and to other psychoanalytical authors, and takes interesting contributions from biology in order to enrich his own theory. For example, he mentions Portmann, a scholar of nature, who emphasizes the purely ornamental value of certain forms of life beyond the mere functions of conservation, comparing the skin to clothes, where the protective effect is not everything; rather, it is accompanied by the striking trait of the model.

 

4 The skin and the levels of symbolisation: from the Ego-skin to the thinking-Ego

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As was pointed out in Chapter 2, Didier Anzieu claims that there is a system of basic traces or representations, the reference of which is tactile, concrete experience. With symbolic development, these representations will be the backdrop against which ulterior operations of thought are inscribed. As these tactile traces are denied and separated, though still maintained, the central idea is that they subsist in parallel with the representations mounted on them, thus configuring different levels of symbolisation. In this way, taking the Ego-skin as a starting point, an Ego capable of thinking and of representing can be formed, an Ego called the thinking-Ego (Anzieu, 1995).

With the understanding that different levels of symbolisation exist, the discussion as to whether a physical disease is from a psychoanalytical viewpoint a phenomenon, a symbol or a symptom could be settled at least in part, because it could be claimed that the disease is a form of symbolisation on a different level to that used in spoken language. In contrast, when the somatic is automatically excluded from the symbolic field, we limit ourselves to saying that where a word, a thought, an affect or a conflict should appear, what does in fact appear is the somatic, and in this case, all things considered, our only theoretical contribution would be establishing a relationship between two things by proposing a simple substitution. Then the theoretical development hides that substitution, seeming to explain in economic terms or by means of formulas and mathemes the way in which the somatic inserts itself into a system, which can be either economic or signifying, and which has been established a priori. In some cases the conclusion is not so different from that of the ordinary observer who, on seeing someone under a lot of stress, says: “Some day or other he will burst”, confirming when he falls ill: “Well, what do you expect, bottling things up for so long? It had to come out one way or another.” Without underestimating folk psychology, we nevertheless get the impression that this kind of interpretation, which is purely economic, is the product of simplification.

 

5 “It works for me”: symbolic efficacy and the placebo effect

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In 2000 the National Psoriasis Foundation (NPF) in the USA published a book containing a selection of comments sent by its members between 1991 and 1999 to a column called “It works for me” in the Foundation’s bulletin. The surprising fact about these comments is that the patients testify to having obtained favourable results by using the most varied and peculiar range of household products, and original combinations of elements intended for cleaning, for veterinarian use or for cosmetic use, as well as lubricating products, and so on, that they used for the treatment of their psoriasis. In an earlier paper (Ulnik & Ubogui, 1998b, p. 117) we stated that the placebo effect can be defined as the difference between the action expected from a drug or healing procedure according to its physical or pharmacological effects, and the action that actually occurs. With this definition we make clear that any pharmacological substance or any physical procedure—even the most powerful—can have a placebo effect which is added to the expected action.

 

6 Reflections on attachment

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My own interest in the theory of attachment stems from my clinical experience with psoriasis patients. Plaque Psoriasis is a chronic inflammatory scaly skin condition. The inflamed skin acquires a red colour (erythema) while the cells reproduce, migrating from the basal layer to the surface with a speed that does not allow them the necessary time to mature and form a cohesive layer, thus generating the permanent development of thick dry scales which can barely adhere to the surface and have a silvery appearance. Patients usually have outbreaks of the disease after key significant episodes, among which separations—due to divorce, migration or the death of loved ones—occupy a very important place. In keeping with the aspect of separations, it has been observed that patients can show an extraordinary dependence on the therapist, or in contrast, a tendency to become detached, to want to get away or suddenly “disappear” from treatment at the first opportunity that presents itself, which could be anything from a holiday to a long weekend or a change in the schedule. In the same way, they may come back to treatment after a while as if nothing has happened, displaying a trusting and friendly attitude and without accounting for or making any reference to their absence, even if it has been quite lengthy.

 

7 The case of Mr Quirón

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In the previous chapter the concepts of attachment, proxemics and affective distance were connected, and were then related to the subjective construction of space. In the following case material the implications of these concepts will be shown.

Quirón is an intelligent, cultured 47-year-old man who works as a biologist at a prestigious pharmaceutical company. A widower with two children, he is the youngest of four siblings, and was raised partly by his mother, partly by a maid whose name is Apacible,1 and also by his elder sister. He became ill with psoriasis when he was 18, and he has consulted me because his disease is greatly extended and he has not found any lasting positive response with previous treatments. This is his first experience of psychoanalytical psychotherapy. The son of elderly parents, he became used to playing alone and to receiving the attention given to an only child, although this attention was divided between the three women.

As an adult, his relationship with women is conflictive: feeling passionate towards them, he easily establishes relationships with them due to his good looks, his culture and his social position. However, he fears that once he falls in love with a woman, she will smother him, wanting to attach herself to him and depriving him of his personal space and independence. At the same time, he cannot bear not to have a woman devote her attention exclusively to him, and he feels uncomfortable if a woman neglects him to look after children from a previous marriage or a relative. He dedicated a great part of his life to his wife, who had become depressed and started to deteriorate long before she died, thus affecting his sexual life as well as the couple’s social life. All his efforts to help her and change the negative direction of her life were in vain. He was left with the feeling that he loved someone who would not let herself be mended.

 

8 Body image and the psychosomatic patterns of childhood. Medical publicity regarding the skin

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When a child is born, he receives a series of stimuli with which he will construct his body image. With a pedagogical objective, they will be grouped arbitrarily into three categories:

•  Sensoperceptive stimuli

•  Interaction with the Other1 who speaks with him

•  Visual images both of himself and of the helpful person

Although the three categories are, all things considered, senso-perceptive stimuli (in which case we could say that the first category in fact includes the other two), here they have been artificially separated since each of these stimuli has a different influence.

Among the sensoperceptive stimuli, those received by exteroceptors, proprioceptors and interoceptors will be emphasised. We must also add to these the so-called superior sensations (DeMyer, 1976).

These receive sensations of vision and of sound, olfactory sensations and cutaneous sensations. The main sensations provided by the cutaneous exteroceptors are the superficial sensations of the skin: tactile sensations, temperature, superficial pain, and itching and ticklish feelings.

 

9 Pathomimias: self-inflicted lesions on the skin

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In the departments of psychiatry and dermatology, the knowledge, experience and vocational service of doctors is usually structured or compartmentalised in a certain way, as a natural corollary of specialized medical training. Psychiatrists and psychoanalysts face the multiple challenges of promoting mental health in a population assailed by addictions to drugs and alcohol, while at the same time trying to reintegrate mental health patients into society, be they depressive, psychotic, or suffering from any other kind of difficulty in facing reality. Dermatologists always see an enormous number of patients, and they face a vast array of problems ranging from aesthetic preoccupations to cancer. Despite the difficulties each medical speciality experiences, these battles against disease are developed within a predictable framework which does not give rise to misunderstanding.

However, there is a percentage of patients who will see a dermatologist and will also need the help of a psychiatrist or a psychoanalyst. Madhulika Gupta (1996) claims that at least a third of dermatological patients who come for consultation present either undeclared or inadequately diagnosed emotional problems, and that the effective management of the dermatological disorder can only be achieved by including the consideration of associated emotional factors. Many dermatologists acknowledge this fact and accept it, yet they cannot find a way to change their therapeutic behaviour such that it is practical and conforms to the reality of the hospital and the consultations, or the pressure of their workload. In consequence, there is no correspondence between the claims of the scientific community regarding the importance of psychological factors and studies concerning quality of life which are so widespread in psycho-dermatology on the one hand, and the actual reality of the patient-dermatologist relationship or the usual methodology of work (duration of consultations, characteristics of treatment) on the other hand.

 

10 Franz Kafka’s In the Penal Colony: Superego and the skin

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In this story by Kafka, a military officer tries to convince an explorer, appointed as a Judge by the Government, regarding the benefits of a perfect machine which has been created by the late commander of a penal colony. As a means of imposing fair punishment on the inmates, the objective of the machine is the maintenance of wellbeing and justice in the colony, beyond the will of men.

The punishment itself consists of writing on the convicts’ bodies— with sharp needles protruding from the upper part of the machine— the regulation they have broken. This writing carved into the skin gradually penetrates deeper into the body, ultimately bringing about the convict’s death. What is more, the execution is public and constitutes a kind of party, to which everyone in town flocks in order to watch the show.

The explorer must judge if the punishment inflicted by the machine is adequate, in order to sanction a demand from the officer and thus obtain a higher budget for the maintenance of the machine. As the explorer eventually rejects this method of execution, the officer himself submits to the machine and dies pierced by its needles.

 

11 The relationship between what the psychoanalyst hears and what the dermatologist sees

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In “Pathways of mutual influence”, Freud suggests that every modification in the field of biological needs and functions can have an influence on the erogenicity linked to the particular organ that carries out these functions. And likewise, every alteration in an organ’s erogenicity can also affect its biological functions (1905a, pp. 205, 206). If we were to take the skin as an example, we could say that dry skin which has not received the necessary hydration, or sunburnt skin which has not received the necessary solar protection, could both participate in different ways from normal skin in what Freud calls the general current of sexual instinct. And vice versa, highly erotized skin, or in contrast, minimally stimulated skin could become ill in different ways: generating itching, becoming infected with herpes, showing blisters or even eczema (see Chapter 3, section 3.3).

A patient who had a strongly eroticised pharyngo-nasal area used to say that he liked grappa, an alcoholic drink which produced in him a feeling of warmth on the palate that rose up like fire to his nose. In addition, he had nasal polyps and used to snore at night. He had a laser operation to burn away part of his soft palate in order to allow him to inhale more air through the respiratory tract and thus stop snoring. The result was a large inflammation in the area, which later became infected, causing his throat to ache and sting. The snoring persisted. Additionally, he found it very difficult to enjoy life, in particular the things he liked most, as if he were unable to find what brought him pleasure “palatable”. The bucco-nasal mucus, the need to breathe and to swallow, and the erotogenic difficulty of tasting things all followed pathways of mutual influence.

 

12 Psoriasis: Father, don’t you see I’m burning? (The skin and the gaze)

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As we have seen in previous chapters, loving caresses, holding, thermal stimuli, pressure and pain, and the care of cleaning the child leave behind traces which are important in the psychic evolution of the individual. In addition, punishments received and infantile dermatitis contribute to augment and to lend meaning to the particular erogenicity that the skin has par excellence. However, we should not forget that the skin is characterised by being visible and photo-sensitive. This characteristic determines a function of communication and affective expression which is highly important in social relationships.

The descriptions of the mirror stage proposed by Lacan and the theory of the face proposed by Sami-Ali are both examples of how the acknowledgement—and the alienation—of an image has a structuring function. What is more, the image is greatly determined by the condition of the skin and the way in which the subject is looked at. In this chapter, therefore, I intend to develop certain aspects of the relationship between the image, the skin and the gaze.

 

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