Towards a new epistemology

Until a few years ago, psychosomatic medicine travelled under the sign of ambivalence: a disorder which, while expressing itself through the body with the evidence of every somatic sign, seems to refer us beyond the biological panorama. But if this beyond is conceived as a distinct and separate entity that we call “mind”, then, against all principles of unity, we come to propose a model that approaches the somatic symptom in a dissociated way.

In order to move past these dichotomies, many of the conceptions in the psychosomatic field have fallen into “reductionism”: they have claimed to unify the realities at stake by subordinating one to the other, or by introducing links of linear causality according to which one determines the other. The chief representatives of this line are the somatogenetic theories, in which every emotional factor is reduced to a simple neurophysiological reaction, or the psychogenetic theories, which assert that every manifestation of the body is explained by processes of symbolisation.

This is how the crisis of psychosomatic medicine arises: on the one hand, from the contradiction between a requirement of “unity” and dichotomous interpretations that betray this requirement and split the unity being proposed; on the other, from the contrast between the idea that the psychosomatic disorder is a complex phenomenon and reductionist methodologies that dissolve that complexity.

These contradictions can be overcome provided that we turn our gaze towards other perspectives, capable of describing the multiplicity of the components of the phenomenon, by establishing circular correlations and temporal simultaneities that build, upon these correlations — and not upon reductive homologations of one component to another —, the meaning of the phenomenon as a whole. And capable, moreover, of distinguishing, within each aspect of reality, articulated pluralities of levels, by seeking the meaning-generating connections that Bateson called “patterns which connect” (4).

In short, in the light of these parameters, the creation of a new epistemology appears necessary. This new theory of knowledge develops and evolves by drawing on systemic models and on the theories of complexity.

From reductionist models to systemic models: from the body as signal to the body as meaning

The vision of the body, and consequently of the illness that expresses itself through it, varies according to the conceptual models. The reductionist biomedical conception brings into play the analytical method of Descartes, which consists in breaking thoughts and problems down into their constituent elements and then classifying them in a logical order. The body is there reduced to a machine, just as the biological functions of living organisms are reduced to mechanical operations. Descartes states it plainly: “I consider the human body to be a machine. My thought compares the idea of a sick man and a badly made clock with my idea of a healthy man and a well-made clock”.

Three centuries later, the biomedical model continues to rest, as G. Engel points out, on the notion of the body as a machine, of illness as a breakdown of that machine, and of the figure of the doctor as the mechanic charged with repairing it. From then on, if the sick body is reduced to a “natural signal” and expropriated of its meaning, if it can only be “described” and not “interpreted”, it no longer offers any reading or any signification that would allow the doctor to take such paths.

A direct consequence of this Cartesian dualism is that the medical profession has found itself dichotomised: there are doctors who treat the body and psychiatrists who deal with the mind. Hence the psychosomatic patient is a split patient: he is taken for a “body” when his body presents lesions; and if he shows no recognisable alterations, he is referred to the psychiatrist — from which there results a body that, from that moment on, nobody will attend to any longer. In this initial dichotomy, the psychosomatic patient remains completely unrecognised in his wholeness.

Moving beyond these reductionist conceptions presupposes an epistemological transformation, that is to say the capacity to place the parts in circular relation, to speak of “totality” rather than of “summativity”; an approach that integrates the multiple components of the human being: biology, emotions, thoughts, relations with the environment and with the world. A systemic vision that sets, against the reductionist fragmentation of the components, a meaningful organisation of those very components.

From the Batesonian conception of mind — defined not only as immanent to the body, but also to the pathways and messages located outside the body, thus uniting organism and environment — at least two essential aspects emerge. The first is the reciprocal relation between body, mind and environment, as a “circular continuum”: not separate entities, but different aspects of a complex reality. The second is the systemic methodology, which seems to define itself as one of the possible paths out of the impasses of the reductionist models, by meeting the concepts of complexity.

According to this conception, the body as a “living” and “lived” body sums up within itself a meaning that asks only to be decoded, and the bodily symptom can be withdrawn from the meaningless obscurity of biological accidents so as to recover the sense of a communication, of something that wants to be said, of a denunciation. It consequently reveals a knot of suffering where biology and emotionality, interpersonal relations and the rules of the context in which it develops all intersect. Rather than a breakdown to be repaired, the psychosomatic disorder becomes the indicator of a distress that must above all be understood, and that refers not only to the individual who carries it but to the context to which it belongs.

It is the context that gives the symptom its meaning, and only by taking it into account is it possible to decode the symptom. The symptom, bodily though it may be, then acquires a symbolic signification that goes beyond the individual symbol to become a “family metaphor”.

The typology of the psychosomatic family

Family systems caught up in psychosomatic problems are complicated: the delimitation of boundaries between the generations is unstable, with a constant tendency to intrude into the spaces — not only physical but also emotional — of each of the members. They moreover present a low degree of tolerance to conflictual tensions, which prevents disagreements from being made explicit and relationships from being clearly defined; everything unfolds within a unanimous consensus of pseudo-harmony, which denies the presence of any problem other than the patient’s symptom.

Every tension and every worry revolves around the symptom, which shows the protective function that it circularly exerts over family homeostasis. These processes hamper the processes of individuation and differentiation, and further favour enmeshment. In this sense, the myth of “family unity” that must be upheld at any price conceals the phantasy of rupture, with the threat that the appearance of a conflict may break the family apart instead of generating an evolutionary leap.

A model of therapeutic intervention: the sculptures of the present and of the future

This model explores, through non-verbal techniques, the perception of the family’s temporal dimension, understood as a capacity for evolution, and it therapeutically fosters the development of that capacity. Working out sculptures consists in associating the spatial metaphor, always present in sculpture, with the diachronic dimension of time.

Two concepts could be singled out as the ground and the organising principle of this working model. On the one hand, the importance of analogical language, richer in possible significations than digital language, and which moreover makes it possible to stimulate creativity between the system and the therapist and to explore deeper and less obvious emotional levels. On the other hand, it has been observed that families presenting psychosomatic problems are characterised by the arrest of the evolutionary process and by the expression of distress through the body — that is to say, analogically; introducing the construction of sculptures therefore makes it possible to speak their own language, the very one with which they express their conflict.

Now, one of the classical hypotheses about the psychosomatic symptom attributes to it the difficulty, indeed the impossibility, of expressing emotions explicitly, the person choosing, so to speak, the path of the language of the body. But this research located that difficulty in the individual, whereas if one observes a wider context such as the family system, one may postulate that the construction of the functionality attributed to the patient is, more than an individual characteristic, a quality of the system.

In other words, it is the phenomenologically most evident expression, in the symptomatic member, of the interactional patterns and shared myths that rigidly determine communications inside the family system and to which the patient must adapt.

The pioneering work of Minuchin (1978) and the research of Onnis (1985) brought to light, in these families, the tendency to avoid emotional tensions and the making explicit of conflicts. Consequently, the fact of “not verbalising emotions” is not the consequence of their absence, but of a filtering of emotional expressions intended to protect the unity and the apparent harmony of the family system. The language of the symptom, expressed somatically by the patient, is therefore not only the language of the patient’s body, but that of the family body as a whole.

By entering through the very channel that the system uses — the analogical one —, the work with sculptures aims to explore “the unsaid”, what the family does not reveal about itself, that is to say the shared mythical image that the system has of itself.

Sculptures were introduced into the field of family therapy by V. Satir (1972), Duhl and Kantor (1973) and P. Papp (1976). They consist in inviting the family to represent spatially the image it has of itself, through the arrangement of bodies in space, facial expressions and postures, the direction of gazes, the closeness or distance between members, and so on. The whole may possibly be completed by a few comments from the members on what they experienced.

Each member of the family is asked to carry out two sculptures. In “the sculpture of the present”, the “sculptor” must represent the way in which he sees the family today. In “the sculpture of the future”, he will have to represent the way in which he imagines it after a certain time, for example ten years. A variant has been introduced here in relation to Papp’s model, which asks for a representation in terms of a “wish” for change, that is to say of the way in which each member “would like” the family to be in the future. In this setting, the projection of a wish for change is not asked for, because in families with psychosomatic problems the projection into the future is less a representation of change than a representation of resistance to it.

In certain psychosomatic situations, for example in childhood asthma, roles, interactions and bonds appear unaltered, as if the family’s evolutionary potential, or its capacity to “see itself” evolving, were blocked. In other cases intense fears arise, as if change or evolution were experienced as a threat rather than as a collective growth. Here, in the metaphorical representation, there emerge the emotions that express the fear of any transformation that might disturb the stability of the status quo, and in particular the threat represented by individuation and, with it, family disintegration: elements that are clearly observed in the myths and phantasies of family unity.

These myths are born and become organised in the course of the family’s history. Histories that come from the family of origin of each spouse and that create in the nuclear family a complex network of three-generational meanings. Frequently, traumatic events are found in the past of these families: early or unelaborated bereavements, abandonments, premature separations. The theme of “loss” is therefore central there and is associated with emotional experiences of intense anguish.

The structure of the therapy

It is possible to single out three phases:

a) When to propose family sculptures

Some authors (Caillé, 1985; Chasin, 1989) use sculptures from the very first session: this is not possible in families presenting psychosomatic disorders.

The exclusive preoccupation with somatic problems, mistrust and underlying defensive attitudes hide behind an apparent availability; this is why the initial phase of the therapy is devoted to building the therapeutic alliance and creating a climate of collaboration.

The therapist, respecting the timing, will obtain information about the problem and about the family history, avoiding incisive interventions and confining himself to minimal structural moves, centred on the somatic problem or on correlations of emotional aspects. Only at the fourth or fifth session, when a certain level of trust has been reached, are the sculptures carried out; in large families, they will require two sessions (respectively the sculpture of the present and that of the future). The session is closed without making any comment: “We believe that a great many things have been said, we have nothing to add”. At the following session, this material is taken up again in order to build a redefinition of the somatic problem.

b) The redefinition of the symptom as a specific metaphor

The purpose is to broaden the signification of the symptom and to establish its connections with the distress of the family. Working out a redefinition presupposes identifying the symbolism of the symptom and amplifying it, so that it becomes a metaphor of the family problem. The effectiveness of the redefinition depends on the capacity to obtain a specific relation between the “quality of the symptom” and the metaphor of the family problem brought to light in the sculptures. Thus, in a severe case of total alopecia in a 7-year-old girl, the redefinition used was “the impossible attempt to be at one and the same time a newborn little girl and an elderly grandmother, and thus to protect the family from tensions and conflicts”.

c) The final phase of the therapy

At this stage, work is done with the various subsystems, particularly when the identified patient is a child or an adolescent. In families that avoid emotional tensions, it is difficult to focus directly on the conflicts of the marital couple. By using the key of the dominant emotional tonality — family unity and reciprocal good —, it is possible to work with the parents with a view to obtaining greater parental cohesion. Likewise, the marital relationship is transformed, even when the parents’ conflicts are not made explicit; this transformation is no doubt due to the intense emotional climate experienced during the sculptures. In other cases, if the parents manage to make their conflicts explicit, these find a more mature resolution.

Conclusions: a new model for psychosomatics or an epistemology of complexity?

All these considerations lead us to assess the psychosomatic disorder as a complex phenomenon, one that does not allow itself to be confined within the reductionist dichotomies of the classical scientific models and that calls for a new approach, capable of accounting for all the components at stake and for the systemic circularity that correlates them. From this perspective, the term “psychosomatic” proves obsolete if it is reduced to a specific class of phenomena: it proposes, rather, a general paradigm of every human manifestation, in illness as much as in health.

But this broader acceptation rests on an optics of complexity, which recognises a multiplicity of levels that are at once autonomous and interrelated. In this dimension, the Cartesian dichotomous oppositions — mind-body, biological-psychological, natural-cultural, individual-familial — lose their signification. From within this possible paradigm, the mind can then refer us back to the body in order to find it again, the psyche to the soma, nature to culture, and the individual to the group he belongs to.

But accepting the optics of complexity means a plurality of points of view, that is to say a multiplication of interpretative models. The systemic model does not escape this criticism, particularly when it is identified with a holistic model of reality, dangerously all-encompassing. Along this path, one may paradoxically fall back into “the cage of reductionism”.

The systemic approach must be conceived and used as capable of establishing recursive correlations between different levels of reality — from the biological to the psychological, from the relational to the social —, each of which retains its autonomy and its specificity and may require specific instruments of investigation. Accepting complexity suggests giving up the “model”, the “fundamental site” of observation.

To speak of a systemic orientation does not mean substituting one model for another, but rather indicating a method liable to open the way to a new epistemology: “the epistemology of complexity”. To face up to this passage, which entails abandoning the model and consequently renouncing many acquired certainties, is without any doubt a tiring and often painful process; but it can also be extremely fruitful and thus give birth to a “new rationality”.