This was given as part of a workshop-style presentation on the topic of Stress as part of the Psychiatry Society in Swansea
The only main purpose of this presentation is to offer a different conception of stress. I’m trying to stay close to the material here, and I’m going to provide examples whenever I can to illustrate points.
Anything I say today will of course be anonymous, It’s up to you to speculate if some of the examples may be from my own life:
- Noticing a fellow medical student has fingers cracked, bleeding, bitten raw pre-exam
- A patient unable to recall basic facts about their condition, or history
- Medical students stumbling under the questions of a consultant
- A cannula that cannot be placed, despite the juiciest veins
Stress is distinct from anxiety, but subtly so. I’m about to use jargon here, but let me keep it as a distinct formula that we can return to at the end:
Stress is the Desire of the Other misrecognised as Demand
A purely biological reading of stress would be something like: the net total of work made by an organism against homeostasis. Hans Selye defined it as “the nonspecific result of any demand made upon the body, be the effect mental or somatic”. As this theoretically is a psychiatry lecture, we can modify this, by saying that there is no such thing as a somatic effect. Or put in a different way, “If a femur fractures in a clinic, but there is no-body to hear it, does it yell out in agony?”. In his original 1936 letter to Nature, Hans Selye called it the “general alarm reaction”, or a reaction that does not correspond to the noxious substance inflicted on the organism. This will be the model for today; a kind of excess of an initial infliction.
We need to make a distinction here, between a signal and a demand. A signal stands alone, and doesn’t lay any claims to it’s ends or pathology. In the case of chronic pain, the signal can erupt spontaneously without a cause, without a pathology. We need to separate the signal of pain from the reaction; we aren’t talking about a reflex. Pain is a signal. Pain doesn’t ask for a solution, it doesn’t ask for anything, and this is why some can experience it as pleasurable. Is is pre-interpretation. The patient says to us: “I am in pain”, but in speaking, they are already in demand. A patient guards an acute abdomen, but the body is already speaking to us, If the abdomen spoke English, it’d say “there is a problem here”. This is not pain, this is Demand.
Demand is distinct from a signal in that it neccessitates a perciever; it requires an audience. A Demand is a form of communication. It requires two loci (subject a and subject b), and finally a third, in what Jacques Lacan called the Big Other. The Big Other is the virtual identity that verifies our thoughts, our speech, language itself; it imposes laws, it imposes itself without justification. We, as speaking beings, are all subject to the Big Other. If we weren’t, you wouldn’t think I was speaking at all; what you would see is something like an oddly adorned bipedal mammal, making various gestures and vocalisations. And I don’t mean to say that animals don’t talk, but as Wittgenstein said; “If a lion could talk, we would not understand”.
Materialising the Big Other in Medicine is so easy, because in Medicine it is everywhere. It is a Phantom hovering over our thoughts, our actions, our speech. To summon the ghost, merely say the magic words: “but what about the NICE guidelines?”.
A Demand invokes the Big Other, because even before the words have passed the patients lips, the Big Other has replied – this is best expressed in the uncanny realisation that when we speak, we don’t realise it, but we hear ourselves speaking, and even more uncannily; something replies. Perhaps you are somebody that talks to themselves, or know somebody that does. The operative question here would be; who are they speaking to?
Or another example: when you find yourself gesturing with your hands, even when talking on the phone. It’s not a signal, it’s a Demand, but who is listening? The Big Other.
Our patient has typically decided what is wrong with them, what the solution is, or in other words; they have already reduced the signal into a Demand. Reversing this chronology is what a history does. In effect, we have to return Demand into a Signal. Or in psychoanalystic terms, Demand is a defense against the Signal. This is what “ICE” disguises. We think that we can isolate Demand into a neat pocket of a patient history, but Demand speaks irregardless of conscious intention. Demand is everywhere. It's in how the patient is sat in bed, it’s in the facial expression of the patient listening to you, in the inflection of a voice, or a question spoken out of place. But most of all, Demand is an excess. In translation from Signal to Demand, something is lost, but something is gained.
Another jump: Demand is distinguished from Desire in that it doesn’t bring your existence into question; merely your capacity; the questions is “can I do this?”, not “What is being asked of my being?” When we fail to place a cannula, or can’t seem to find the right diagnosis, we sense that we are incapable of meeting a Demand; we meet the image of the ideal doctor, or medical student in our mind, and launch into an imaginary comparison; which at the mercy of the superego is doomed to fail. In this way, we collapse Desire into Demand, to sanitise it. It’s a kind of analgesia. Better that I fail at doing, than fail at being. It is much more tolerable, but the price is stress.
In this transformation from Desire, Demand is never satisfied. This excess of the Demand is precisely where stress makes its appearance. Desire causes anxiety, but Demand causes stress. Demand is never satisfied with what you already have done. There is always a remainder; an excess. Sometimes our positionality relative to those around us can radiate Demand even without the intervention of speech. Think of what you ask yourself when entering a new placement, a new ward, a new social group: how can I be the ideal doctor? What should I be doing? What are others like me that I admire doing in this situation, how can I be more like them? The passage from Demand into Desire would be to recognise the symbolic game of the encounter: there is no being that satisfies Demand. There is no ideal doctor. The people I admire are my own invention. The question of Desire would instead be, In knowing I am determined to fail, what is the new way in which I could fail? Or as Beckett says;
Try again, fail again, fail better
So what, if anything, can be said of Demand, to let us encounter it without crumbling into stress? Firstly to recognise that the Big Other doesn’t know what it wants, even when it is speaking. The question always hides itself. Here’s a little vignette, you will all recognise it:
You enter a new placement. You start a ward round with a consultant. Suddenly, they ask you a question in front of the patient. Tell me about this patient, what can you see, what do we need to know? Of course, you cannot answer precisely what they want; there is no answer that will satisfy the consultant. The question isn’t “tell me about the patient”, the question is a demand: “tell me how much I know more than you, let me prove to everybody around me that I am master in this situation”. Your answer hardly matters. The positions in the game have already been set. The game is already over. So what can we do? Realise that the hidden excess of the Demand is being placed in your arms, without your consent. Do you let the demand circulate in your body after the Demand is placed; perhaps it circles around you in the form of the superego afterwards (I cannot believe I didn’t know that diagnosis! I must revise these topics immediately, else I fail the oncoming exam!) or perhaps something even worse emerges; your answer appears to satisfy the consultant – you start to believe that you are truly “getting medicine”, that your place in the game is secure, so the next time a fellow medical student asks you a question, perhaps you start to try and be in the position of mastery yourself, and make your own Demand. Stress is a kind of linguistic inheritance, a kind of objectification that asks us to play it’s game, if only to hand it on like a hot potato. The gambit is not how long you can hold it, or how quickly you can hand it over, but to change the game entirely.
Earlier I said stress is the misrecognition of Desire as Demand of the Other, but what is this Demand? The Demand is to be the plug in the hole. To seal over the cracks. The question might not be how to better modify ourselves into a human sealant; but instead to ask, what happens of the crack, the hole, the gap, should we let it remain visible? What can It tell us? And even further still, when peering into the gap, what should happen if it makes it’s own Demand?