Moises Enghelberg, DO
Touro College of Osteopathic Medicine, New York, United States

 Technique of manipulating contracted inter-vertebral  ligament in cervical region
 Technique of manipulating contracted inter-vertebral 

ligament in cervical region. (World War I era)
Otis Historical Archives National Museum of Health and Medicine


As a point of departure is the notion of space and the value given to personal space in therapy. Space, the dialectic force by which touch and closeness is defined, functions in therapy as a sort of barrier between two individuals and allows the physician to maintain distance, but also gives a place for patients to have amplitude in communicating what they are feeling, suggesting there is room for touch and contact.

There is a very transparent idea in Derrida’s1 On Touch when he cites Freud’s dying words: “The psyche is expansive: and I don't know anything about it.”

Derrida argues that this expansiveness, was a direct reference to Kant in his Critique of Pure Reason, when he states that “Space is a necessary a priori representation, which underlies all outer intuitions”. For Derrida, Freud confirms that pure intuition “must be found in us prior to any perception of an object” and that consequently, that space must be pure sensibility ... a kind of sensibility of touching nothing? Or a kind of touch without empirical contact, a self-touching or being touched without touching anything?

This raw touch that Derrida mentions, exemplifies the state where much of psychoanalytic practice has dwelled upon; evoking this space as something dense and material by which the analyst and analysand are confronted with and work on.

The advancement of psychotherapy will not come from increasing the distance and spaces between patient and therapist, but by creating spaces in which the patient feels closer to the caregiver. This can be done by implementing techniques that enable the physician not only to understand the discourse of the patient, but also the difficulties of their bodies. Space and touch do not oppose themselves directly, rather they have their own values, their importance, and their proper function: they complement each other.

You shalt not touch

A time-honored prohibition states that psychiatrists and the psychotherapists must not touch their patients. Likewise, it is understood that osteopathic medicine, in particular osteopathic manipulative medicine, posits as a necessity touching the patient. It is the precise center of that therapeutic milieu.  Herein, a proposal is made to meld these two clinical specialties into one, creating a new specialty of medicine in which psychotherapeutic diagnosis and the manipulation of muscle and fascia are combined as part of the curative process. It is well established fact that the muscle bears memory, remembering its effort, its contraction, its strength2 also, in a deeply psychic manner, that muscle injury reflects current as well as past experience. Muscle tightness and rigidity accumulate to express memory; for instance pain being one of the extreme manifestation of tactus, is an incisive state that alters all emotion, signifying that the body is present.

Such knowledge allows physicians to gain a deeper understanding of the interplay of psychic and physical forces.  This approach provides greater effectiveness for all physicians, and creates an ever-expanding universe for patient care as entry point to a deep psychological script. Even touching the patient in the affected region evokes memories and regressions. It is at this level that psychoanalytic approach of the therapist and the manipulative skills of the osteopathic physician meld.

Chronic myofascial pain, muscle and joint rigidity, incapacity derived from fatigue and stress, psychosomatic injuries, and other forms of such disorders can thus be approached in an entirely new manner. As patients express themselves through their bodies, the analyst needs to be aware that at times words do not suffice.

At the beginning of any healing session, traditional Mexihka-Aztec healers take the pulse of their patients. Through it they gather information about their general state, feeling their energy and temperature and overall disposition. The traditional practice of “pulseo” (feeling the pulse) establishes a preliminary report between patient and healer, its intensity, rapidness and localization enabling  the practitioner to decode the presence of disease, even that of an emotional nature.3 Feeling the pulse of the patient can be viewed not only as a therapeutical device, but as a gesture where the physician extends his hand to the patient, and most importantly feels him. For a moment the analyst and the analysand coalesce, and the physician becomes the host of the other. 

A missing link

The link between touch and psychoanalytic practice has heretofore been overlooked, and osteopathic medicine is a way to reconnect the discourse machine and its tactility.1  As this dualistic perspective reigns over much of the medical landscape, disease is seen either as a purely somatic or entirely mental, a formulation put into place because of the need for simplicity. But illness takes precedence over disease, and that memory; the mind manifests through the body; and  the body is the witness to the experience of what Heidegger4 called being-in-the-world, an experience that cannot be consummated outside of touch.

It seems that an integrated relationship between the suffering of the body and its psychological implications has been constantly fractured. Body and mind do not merely cohabit, they dwell simultaneously and function in the same place. Osteopathic medicine and psychoanalysis are both very capable methods of recovering feelings, histories and memories, and a combined psychiatric and osteopathic gaze could establish a bond between the bodies and minds of our patients. 


One of the most outstanding terms in the Lacanian approach is jouissance: an enjoyment that takes part within the body (or at times outside) of an individual. An enjoyment that has libidinal as well as unconscious repercussions, so profound that at times the person is cast out from the body and from the experience. It is here, at the heart of this term that osteopathic medicine and psychoanalysis overlap. Jouissance covers the body of the patient and the analysand, and the touch of the physician becomes a method for recovering the source of the phantom of jouissance.5

To better delineate this idea, let us introduce a passage from Juan David Nasio, a psychoanalyst of the Lacanian tradition. After attending a ballet performance, he provides a helpful description of the concept of jouissance:

At last I had an observation which I wrote down on a letter directed to my friend Leclaire: I  
think I have found the place of jouissance in ballet. It is, curiously, in Bartoluzzis feet. Why 
the feet? For two reasons. First because during the sequence, in my way of seeing, the feet of
the dancer concentrate all the tension of the body in equilibrium. And later, because
Bartoluzzi worked his body to such a point and had made use of it in such a way, meaning,
he had made so much life pass through that fragment of his body -let us imagine the
discipline and the rigor of that man which was already a consecrated artist-,’ I did not fumble
to write that Bartoluzzi had lost that foot. From the point of view of jouissance, he separated
himself from it constantly. The foot had become the place of the body that truly does not 
belong to the dancer.5

This loss, is a loss meant as an action and as a feeling, which constitute the primary workings of this concept; for all purposes we could establish that jouissance=losing. Losing interpreted in a context of separation, of segregation from the rest of the body, a breakage from that biological unity that operates within the body. Jouissance functions as a psycho-pathological mechanism which dismembers the body, and deposits itself on an organ, an extremity, establishing a biological as well as a psychological reflex. It becomes so integrated into the body of patients  that they ignore its existence. This separation directs the body of the patient. The organ that experiences the jouissance synthesizes a diffuse volition that operates within the patient, eventually separating the anatomical structure (from the totality of the body) which feels the jouissance.      

Somatic dysfunctions

A “somatic dysfunction” is the epistemological base of osteopathic medicine. Its presentation does not readily signify a pathological state unto-itself, rather the presence of underlying processes. A somatic dysfunction is often much more, revealing itself as a cover through which different layers interact. The eyes of the osteopathic physician constantly look for symmetry and proportion, his hands palpate for pain and discomfort. Tissue texture changes, rotations of the vertebra, decreased rib excursion, decreased ranges of motion, lead to neuromuscular damage and are manifestations of a pathological states which appear in a patient. If the goal of the analyst is to comprehend the patient’s  overall state and establish an analytical relationship, this requires sharing the symbols of language as well as  the signs and symptoms of the body. Somatic dysfunctions do not directly indicate psychological stress, but an overall physiological sensation.

One of the fundamental notions of osteopathic medicine is the idea that “the body works as an integrated unit, and everything within it is related.”6 The psychological concept we have presented earlier runs in a parallel fashion with the beliefs of the osteopathic manipulative medicine. The concepts travel the same road, but in different lanes. If a certain part of the body is separated from the overall unit, it is to be considered analogous to a pathological state. The autonomy of a certain organ or an extremity from the whole becomes in the osteopathic view the source of disease. The separation not only affects the bodily organ that has become detached, but at the same time affects the rest of the body. The body integrates all of its anatomical parts and relates to them in an infinite loop, at times some of the pieces of the structure altering  the energy flow of the loop and creating a stress or an alteration to the health of this structure. Lacan analyzes a similar concept in the “The Mirror Stage as a Formative Function of the I7 stating that “a succession of phantasies that extends from a fragmented body to form an orthopaedic image of the self” to which he adds that “the assumption of the armor of an alienating identity, which will mark with its rigid structure the subject's entire mental development.” Lacan synthesizes a process by which the body incorporates itself into a totality, a way of seeing the body as a unity. But we should add that that it does not purely satisfy us, it is not only the way we see ourselves, but how we feel our bodies, and command them to seek pleasure and be comfortable within them. It is the impending necessity of the self to be able to present itself to the other and explore the construct of his own “orthopedic image.” When the “orthopedic image” is fractured, or a part of this totality is broken, illness ensues.

Repetitive Stress

Repeated stress to an organ or component of the body irritates a specific anatomical segment , that in osteopathic epistemology is known as facilitation of the segment.6 This leads to a pronounced excitation of the sympathetic nervous system,  maintaining a state of constant tension and arousal. The segment may be activated by reflexes of either the somato-somatic or viscero-somatic type.6 While facilitation works in a physiological level to maintain and separate the organ, jouissance operates in a psychological plane that has deep physiological ramifications.

It may be possible to incorporate these concepts into a grid containing different planes that run parallel and vertical to each other. The concepts intercept in multiple ways; Lacanian psychology stumbles upon osteopathic medicine in a fortuitous manner. This two realms deal with the same issue but with different language. The subject of study remains the same: the way by which life experiences deposit themselves in the body and how they binds to it. These two vocabularies complement each other.

It is rather difficult to comprehend which of these concepts of pathology occur first, and which evokes the latter; the aches of the body might become a sort of  jouissance for the athlete; the stomach of the alcoholic is the depository of pain and abandonment. There are cases in which schizophrenics lose sense and the feeling of ownership over their own bodies.8 There is a pervasive entanglement  between mind and body, and the self they share; it is difficult for the physician as well as for the analyst to find the seed through which a state of disease sprouts from. Because of this, there exists a latent complexity of considering pathology a psycho-somatic experience. Disease is a complex figure bound by the coherence of a single unity, and not a mixed reality of crossbred essences.9

There are cases in which patients begin to identify themselves with their conditions: pathology functions as a category by which to define the self. They internalize their diagnosis, further complicating the baseline condition and its eventual repercussions. The process of identification vis-a-vis disease, serves to structure the identity of the patient and to reconcile the body and the psyche. The internalization of what we may call the “Ill-I,” results in the deposition of another sort jouissance in the mind of the analysand, by which the patient suffers, enjoys and lives through, within their disease/diagnosis.

The incorporation of these disciplines might be a new tool by which the practitioner grasp and dissect the complexity of the forces involved in the current state of their patients by understanding the texture of the body and the mind as a unity.


  1. Derrida J. On Touching - Jean-Luc Nancy. Stanford, California: Standford University  Press; 2005. pp. 36-46.
  2. Bruusgaard, JC, Johansen IB, Egner IM, Rana ZA, Gundersen K. Myonuclei acquired by overload exercise precede hypertrophy and are not lost on detraining. Proc. Natl. Acad. Sci. U.S.A, 2010; 107(34):15111-6.
  3. Hinostroza, G. & Peraldi, D. Chamanismo, Medicina y Religión de los Pueblos Originarios de Tradición de Alta Cultrual Americana.Bloomington, Indianapolis: Palibrio; 2001. pp. 114-115
  4. Heidegger, M. (1996). Being and Time.New York, New York: State University of New York; 1996.
  5. Nasio, JD. El Placer de Leer a Lacan. Barcelona, Spain: Editorial Gedisa; 2008 pp. 29-51.
  6. DiGiovanna, EL, Schiowitz, S. An Osteopathic Approach to Diagnoses and Treatment. Philadelphia, PA: Lippincot, Williams & Wilkins; (1991).
  7. Lacan, J. Ecrits. New York, New York: W. W. Norton; 1977.
  8. Thakkar, KN, Nichols HS, McIntosh LG, Park S. Disturbances in body ownership in schizophrenia: evidence from the rubber hand illusion and case study of a spontaneous out-of-body experience. PLoS One 2011; 6(10): e27089. 
  9. Foucault, M. El Nacimiento de la Clinica: Una Arquelogia de la Mirada Medica. Mexico City, Mexico: Siglo Veintuno Editores; 2001. pp. 145

Moises Enghelberg, DO, is a recent graduate of Touro College of Osteopathic Medicine - NY, Harlem. He also has a master’s degree in Interdisciplinary Biological and Physical Sciences. He is currently an ophthalmology resident in New York. His literary work strives to expand and enrich medical practice by cross-pollinating unseen connections between fields.