The 3 French Component Societies APF (French Psychoanalytic Association), SPP (Paris Psychoanalytic Society) SPRF (Psychoanalytic Society for Research and Training) have requested that we publish the following report. The report was written together with many other non IPA Psychoanalytical Associations present in France. The "Report on the Progress and Contributions made by French Psychoanalysts in the Field of Mental Health, Youth and Culture" is intended for policymakers and government officials in the French mental health field, as well as for the interested public.
Report on the progress and contributions of French
psychoanalysts to the field of mental health, youth and culture
Keller Pascal-Henri, Professor Emeritus, University of Poitiers, Psychologist
Landman Patrick, Psychiatrist, Jurist, Psychoanalyst
Bantman Patrick, Honorary Hospital Psychiatrist; Medical Mediator at Hospitals in Saint Maurice, Psychiatrist at the French Office of Immigration and Integration (OFII)
Bataillon Nathalie, Filmmaker, Psychoanalyst
Belamich Patrick, Psychiatrist, Psychoanalyst, Medical Director at CMPP Fontainebleau
Bergès Bounes Marika, Clinical Psychologist, Psychoanalyst, formerly with the Child and Adolescent Psychopathology Unit, Sainte Anne Hospital Centre
Carbunar Jean-Michel, Psychoanalyst, Psychodramatist
Chaperot Christophe, Psychiatrist, Chief Physician at Abbeville Hospital Centre, Psychoanalyst
Chemla Patrick, Psychiatrist, Psychoanalyst, Director of Antonin Artaud Centre, University Hospital Reims
Croix Laurence, Associate Professor (MCF) of Psychology and Education, CRPMS EA 3522, Paris Diderot University, CS COMUE Paris-Lumières, Psychoanalyst
Dana Guy, Psychiatrist, Psychoanalyst, Former Chief Physician at GH Longjumeau
Darmon Marc, Psychiatrist, Psychoanalyst
David Marielle, Child Psychiatrist, Psychoanalyst, Former member of CNCDH
Douville Olivier, Associate Professor (MCF) of Psychology, CRPMS EA 3522, Psychoanalyst
Drapier Jean-Pierre, Psychiatrist, Medical Director at CMPP Orly, Psychoanalyst Fischman Georges, Hospital Psychiatrist, Psychoanalyst, Director of the Centre for Clinical Epistemology, Sainte Anne Hospital Centre
Forget Jean-Marie, Psychiatrist, Psychoanalyst
Gailis Janis, Psychiatrist, Medical Director at CMPP in Montreuil, Psychoanalyst Garcia-Fons Tristan, Child Psychiatrist, Medical Director at IME Jean Macé in Montreuil, Psychoanalyst
Godart Elsa, Philosopher, Psychoanalyst, Director of Research at Paris-Est Créteil University, Associate Professor (HDR) at Paris Diderot University
Lamrani Tissot Rhadija, Psychoanalyst, Linguist, Essayist
Robert Levy, Doctor of Clinical Psychology, Psychoanalyst, Associated Researcher at Aix Marseille University, Former Supervisor at CMPP Montgeron
Markman Nora, Clinical Psychologist, Paris Diderot University, Psychoanalyst at CMPP Fontainebleau
Najman Thierry, Psychiatrist, Psychoanalyst, Director of the EPS Unit in Moisselles
Patris Michel, Psychiatrist, Psychoanalyst, Honorary Professor of Psychiatry at the University of Strasbourg
Pommier Gérard, Psychiatrist, Psychoanalyst, Professor Emeritus at the University of Strasbourg, Director of Research at Paris Diderot University
Sciara Louis, Psychiatrist, Psychoanalyst, Medical Director at CMPP Villeneuve Saint Georges, APSI
Sedat Jacques, Philosopher, Psychoanalyst, Secretary of the Contact Group
Tourres Landman Dominique, Psychiatrist, Psychoanalyst, Medical Director at HDJ CMPP Ville d'Avray
Publishers of contributors:
Albin Michel; Armand Colin; Aubier; Campagne-Première Editions; De Bœcke; Doin; Dunod; Editions Universitaires Européennes; Erès; Fayard; Flammarion; Gallimard; Hakusuisha Publishing Co. Tokyo; Hermann; In Press; Ithaque; La Découverte; Larousse; Les Belles Lettres; L’Harmattan; Masson; Max Milo; Michel Lafon; Odile Jacob; Ovadia; Payot; PLON; PUF; Privat; Scrineo; Seuil
Chaboudez Gisèle, Psychiatrist, Vice-President of Espace Analytique
Even-Leberre Catherine, Psychoanalyst, Vice-President of Quatrième Groupe OPLF
Gentizon Jean-Michel, Honorary Psychiatrist, Psychoanalyst
Godefroy Hélène, Psychologist, Psychoanalyst Espace Analytique
La Gorce Bernard de, Psychoanalyst, APF, Lyon
Leguil François, Psychiatrist, Psychoanalyst
Legouis Jean-Baptiste, Secretary General of RPH
Maleval Jean-Claude, Professor Emeritus at Rennes 2 University, Director of BAPU, Psychoanalyst, Member of the École de la Cause Freudienne and the World Association of Psychoanalysis
Rafowicz Emile, Psychiatrist
Sapriel Guy, Psychiatrist, Psychoanalyst
Vanier Alain, Professor at Paris Diderot University, Director of CRPMS
Vanier Catherine, Doctor in Psychology, Paris 8 University, Associated researcher at Paris Diderot University
- Groups and Associations
Analyse Freudienne http://www.analysefreudienne.net/
Association Lacanienne Internationale* https://www.freud-lacan.com/
Association Psychanalytique de France https://associationpsychanalytiquedefrance.org/
Cercle freudien https://www.cerclefreudien.org/
École de la Cause Freudienne*
École de Psychanalyse des forums du Champ Lacanien https://www.champlacanien.net/
Espace Analytique http://espace-analytique.org/
Fédération des Ateliers de Psychanalyse http://www.federation-ateliers-psychanalyse.org/
Fédération Européenne de Psychanalyse https://www.epf-fep.eu/fre
Psychanalyse actuelle http://www.psychanalyseactuelle.com/
Quatrième Groupe https://www.quatrieme-groupe.org/
Réseau pour la psychanalyse à l’Hôpital http://www.rphweb.fr/
Société Psychanalytique de Paris*
Société de Psychanalyse Freudienne https://www.spf.asso.fr/
Société Psychanalytique de Recherche et de Formation http://sprf.asso.fr/sprfwp/
ALI: Association lacanienne internationale (International Lacanian Association)
AMP: Association mondiale de psychanalyse (World Association of Psychoanalysis)
APF: Association psychanalytique de France (French Psychoanalytical Association)
API : Association psychanalytique internationale (International Psychoanalytical Association, IPA)
APSI : Association de prévention, soins et insertion (Association for Prevention, Care and Integration)
BAPU : Bureau d'aide psychologique universitaire (Student Psychological Support Centre)
CAMPS : Centre d'action médico-sociale précoce (Early Medico-Social Intervention Centre)
CATTP : Centres d'accueil thérapeutiques à temps partiel (Part-time Therapeutic Centres)
CH : Centre hospitalier (Hospital Centre)
CHU : Centre hospitalier universitaire (Teaching Hospital)
CNCDH : Commission nationale consultative des droits de l’homme (National Consultative Commission for Human Rights)
COMUE : communautés d'Universités et établissements (Groups of Universities and Institutions)
CRPMS : Centre de recherche psychanalyse, médecine et société (Research Centre for Psychoanalysis, Medicine and Society)
CS : Conseil Scientifique (Scientific Council)
ECF : École de la cause freudienne (School of the Freudian Cause)
ENM : École nationale de la magistrature (French National School for the Judiciary)
EPS : Établissement public de santé (Public Health Facility)
FDCMPP : Fédération des centres médico psycho pédagogiques
(French Federation of Medico-psycho-educational Centres)
GH : Groupe hospitalier (Hospital group)
GIS : Groupement d’intérêt scientifique (Scientific interest group, SIG)
HDJ : Hôpital de jour (Daycare Hospital)
HDR : Habilité à diriger des recherches (French academic rank, authorised to supervise research, equivalent to Associate Professor)
IME : Institut médico-éducatif (Medico-Educational Institute)
IPA: International psychoanalytical association
MCF : Maître de Conférences (academic rank equivalent to Lecturer)
OFII : Office français de l’immigration et de l’intégration (French Office of Immigration and Integration)
OPLF : Organisation psychanalytique de langue française (French-Language Psychoanalytic Organization)
PH : Praticien hospitalier (Hospital Practitioner)
RPH : Réseau pour la psychanalyse à l'hôpital (Psychoanalysis in Hospitals Network)
SEPEA : Société Européenne pour la psychanalyse de l’enfant et de l’adolescent (European Society for Child and Adolescent Psychoanalysis)
SIUEERPP : Séminaire interuniversitaire européen d’enseignement et de recherche en psychopathologie et psychanalyse (European Inter-University Teaching and Research Seminar in Psychopathology and Psychoanalysis)
SPP : Société psychanalytique de Paris (Paris Psychoanalytical Society)
UNAFAM : Union nationale des amis et familles de personnes malades psychiques (National Union of the Friends and Families of Mentally Ill)
Table of Contents
A – Psychoanalysis, Scientific Criteria and Efficacy
1) Historical background
2) Current situation: Science, psychoanalysis and scientific criteria
3) The Contributions of psychoanalysis and recommendations
B – Psychoanalysts and Institutional Practices
1) Historical background
2) Current situation
3) Recommendations and innovative practices
C – Psychoanalysis, Children and Youth
1) Historical background
2) Current situation
3) Recommendations and innovative practices
D – Psychoanalysis and Culture
1) Historical background
2) Current situation
3) Recommendations and innovative practices
The events and social issues of recent years have repeatedly put psychoanalysis and/or psychoanalysts in the spotlight. In the minds of the public and political decision-makers, the discipline founded by Freud in the early 20th century remains linked to fragmentary and heterogeneous ideas and is often seen as controversial. And yet, directly or indirectly, French citizens are increasingly more often confronted with psychoanalytic ideas, both in the social and professional context or in their private lives. The contrast between, on the one hand, this utterly non-hegemonic influence of psychoanalysis and, on the other hand, the sporadic yet at times malicious attacks on the discipline, has prompted the decision of a number of experts to try and assess the current state of psychoanalysis in France and present to all those concerned the key challenges of this seemingly paradoxical situation.
These experts invariably have a long and rich psychoanalytic experience. Their report helps identify the key contributions of their discipline and its role in specific fields. It is divided into four chapters: 1) Psychoanalysis, Scientific Criteria and Efficacy; 2) Psychoanalysts and Institutional Practices; 3) Psychoanalysis, Children and Youth; 4) Psychoanalysis, Culture and the Media. The authors have adopted a methodology of working in groups formed around these four key spheres. The bibliographical references for each chapter have been included in the report and are publicly available.
In order to harmonize their presentation and make it more accessible to the reader, each of the four chapters is organised into three parts:
-Recommendations and innovative practices
Entitled Report on the Progress and Contributions Made by the French Psychoanalysts in the Field of Mental Health, Youth and Culture, this document is intended for policymakers and government officials in the French mental health field, as well as for the interested public. Some have claimed that psychoanalysis no longer meets the needs of this sector. In this context, the report describes not only the majority of actions developed and implemented by French psychoanalysts but also their ability to make concrete proposals. More generally, it looks at the productive presence of psychoanalysis in the French cultural landscape and its influence beyond our national borders.
A – Psychoanalysis, Scientific Criteria and Efficacy
1) Historical background
Summary: After the beginning of 20th century, Freud’s desire to include psychoanalysis in the field of science cannot be denied. Our aim is to distinguish between, on the one hand, the discussions within the scientific field, which strive to develop psychoanalysis as a discipline and, on the other hand, partisan debates that conceal from the public as well as political decision-makers the true rigour of psychoanalytic theory and practice.
The professional goal of the founder of psychoanalysis, indeed the “chief interest of [his] life”, was scientific research. In May 2006, the New York Times dedicated a long article to Freud’s scientific career, from his neuron observations at the end of 19th century to his models of the psychic apparatus in the 1930s. On many occasions and in most of his writings, Freud proved that the framework of his thinking indeed remained scientific; his initial training was in the natural sciences rather than medicine.
Today known as The Project for Scientific Psychology, Freud’s first important paper on psychology was described by him as a “Psychology for Neurologists”. As for the term “unconscious”, today’s symbol of psychoanalysis, Freud thought as early as in 1915, that it was a psychic state rather than some mysterious area of the brain. His Project intended to be “engaged scientifically in the construction of hypotheses” of the unconscious. The goal of this scientific work was not so much to discover “an” unconscious but rather to study the hypothesis of a “second consciousness which is united in one's self with the consciousness one knows”. This formulation enables each of us to recognize, in ourselves, the presence of unconscious psychic activity, the origin of which remains inaccessible to us unless we engage in personal analytic work and the effects of which are observable in everyday life (slips of the tongue, bungled actions, dreams, etc.).
Psychoanalysis is therefore concerned with phenomena which are, above all, the results of the observable effects on the conscious processes of speech, initially received in the framework of the treatment. Freud’s interest in science was fuelled by his commitment to truth – a modern and scientific truth, rather than one that is metaphysical and speculative, religious or revealed. Nevertheless, the scientific truth of psychoanalysis differs in certain respects from the scientific truths of experimental sciences. The truth that emerges from the psychoanalytic experience originates, for the individual subject, from the narrative operation of speaking. By virtue of being listened to by a psychoanalytically-trained professional, this truth can then be transmitted, and its transmission is subject to the rationality specific to the community of those working in the psychoanalytic orientation.
In the text he was working on just before his death, Freud made many more links between the psychoanalytic method and those of other natural sciences. For example, in the following commentary on the facts whose emergence and development psychoanalysis strives to understand: “The processes with which it is concerned are in themselves just as unknowable as those dealt with by other sciences, by chemistry or physics, for example; but it is possible to establish the laws which they obey […] in short, to arrive at what is described as an ‘understanding’ of the field of natural phenomena in question. […] They can lay claim to the same value as approximations that belongs to the corresponding intellectual scaffolding found in other natural sciences.” The parallels made by Freud between his own life-long scientific activity and those of other researchers are unambiguous: to him, psychoanalysis endorses the ambitions and approaches of any other scientific discipline.
Among the legitimate criticisms of this new science, some have put forth solid arguments, while others have expressed prejudice that reveal partisan judgment rather than the spirit of a genuine scientific debate. Furthermore, some of the arguments contesting psychoanalytic knowledge come from a field Freud tried his best to distance himself from – philosophy. The most heavily mediatized accusations made against psychoanalysis over the past decade have come from a philosopher, Michel Onfray, who himself has faced much criticism not only from fellow philosophers but also from historians, sociologists and of course psychoanalysts. His critique has focused on the personality of the founder of psychoanalysis; it has been dominated by virulent and unqualified discourse, poorly documented and resembling a trial rather than a serious debate. The title of this work – Twilight of an Idol – is evocative of the author’s aim, a quasi-mystical settling of scores with a major intellectual figure of the Western world, which has nothing in common with the requirements of a rigorous discussion founded on scientific logic and likely to truly enlighten the audience.
Contrary to this polemical and caricatural tone, other authors have offered a criticism of psychoanalysis from a genuinely epistemological perspective, bringing new insight into the debate rather than obscuring it. For example, Renée Bouveresse and Roland Quilliot contested psychoanalytic theory by arguing that Freud tried to make psychic facts into “material realities”. The philosopher Adolf Grünbaum called for a “philosophical critique of psychoanalysis”, but his argument relies on the model of physical sciences rather than philosophical rhetoric. For instance, he argues that Freud wished to create a science similar to those from which he had borrowed his models: chemistry, physics, physiology, etc. However, a close reading of Freud’s texts shows that while he indeed used the medical vocabulary of his time and certain medical concepts to demonstrate some of his ideas, it was only to highlight the limits of these analogies and establish the theoretical foundations specific to psychoanalysis. The notion of “psychic energy”, for example, was proposed by Freud as a “model” of the “economic” principle of psychic life. Only Wilhelm Reich, his somewhat exalted disciple, gave this energy the status of physical and concrete reality, trying to isolate it and preserve it using an accumulator.
A century of research into the validity of psychotherapies could not avoid subjecting psychoanalysis to the same requirements as other therapeutic models. The results have generally been mixed, because no psychotherapy truly meets the criteria of experimental science. Initially, psychotherapies were created without verifying their efficacy or understanding clinical questions, or even justifying certain preliminary theories. The validity of the knowledge constituted by these methods is based on its heuristic value, as the sole reference of its technical approach. Their proximity to medicine at first led psychotherapies to claim their status based on evidence-based medicine, and later turn towards the model of empirically supported treatments. Obtaining this label based on a certain number of criteria nevertheless remains problematic. The idea of adopting EBM criteria is founded on two apparently unrealistic assumptions: (1) the uniformity of psychotherapists, who are asked to behave identically and (2) the presumed homogeneity of patients, who are divided into groups also seen as homogeneous.
The main difficulty in studying the evidence of psychotherapy’s efficacy has to do with the very nature of what is being measured, as well as the questions researchers must answer. Windelband sheds light on this debate by distinguishing between the nomothetic approach of the natural sciences (in this case medicine) and the idiographic approach of the humanities (in this case the study of the psyche). The distinction between normality and pathology, which is at the heart of each demand for psychotherapy, relies on individual norms that resist predictable generalizations and are likely to be imposed as rules by social normalization.
Finally, we find two opposing validation paradigms within the psychoanalytic community itself. The first group, which defends the hermeneutic approach, believes that complex interactions can only be validated by interpreting singular clinical cases with respect to the consistency of psychoanalytic theory and its clinical deductions. They recommend a specifically psychoanalytic approach to research (Leuzinger-Bohleber, Waldron). Others, more in favour of the possibilities of empirical verification, emphasize the need for making connections, albeit partial, with other related disciplines, in order to provide evidence of the true efficacy of psychoanalytic therapies, subject to the existing criteria of legitimacy (Westen, Luborsky).
An alternative to psychotherapeutic research is single-case design. Already used and recognized in medical research,this idiographic paradigm believes in the need of recognizing the singular case as a valid source of knowledge including in the study of psychotherapeutic processes. Contrary to the extensive group protocol based on a homogenous sample and statistical generalization, the intensive single-case protocol is focused on the systematic in-depth study of a single clinical case.
Today, the overall validation of psychoanalytic therapies requires a multiple strategy involving a range of verification methods, both theoretical and empirical, to ensure we maintain the utmost quality of psychotherapeutic care for the highest possible number of patients.
2) Current situation: Science, psychoanalysis and scientific criteria
Summary: The contributions of psychoanalysis to the field of mental health have received little media attention. They are nevertheless real and are continuously explored by researchers around the world, who are trying to assess their relevance and interest for the general population. These studies have been investigating the validity of psychoanalytic concepts on three levels: technical, therapeutic and theoretical.
Contrary to the ambitions of psychiatry, which, like other medical specializations, seeks to base its practice on scientific evidence (see below), psychoanalysis sometimes appears to take a different approach. This impression is based on three things: the nature of the object it studies, i.e. unconscious psychic life; the subjective status of the person concerned by the study of his or her unconscious life; the method that enables us to study unconscious thoughts, i.e., interpretation.
1)Contrary to the behaviours and symptoms observed by psychiatry, psychoanalysis studies an “unconscious” that cannot be directly observed;
2) unconscious thoughts are by definition unknown to the subject; they escape the position of the “reliable witness” from which they could be studied;
3) to access unconscious thoughts, the psychoanalyst has to use interpretation, the same way that a cardiologist “interprets” an ECG curve, or a radiologist interprets the ultrasound of an organ: by relying on a competency developed through experience.
As if to combine these three arguments into a single one, epistemological critique regularly tries to question the scientific value of psychoanalysis. This approach, based on the ideas of Karl Popper, argues that any theory that claims to be scientific has to be falsifiable. While as an individual, Popper was convinced of the existence of an unconscious world, as a logician he believed that the impossibility to falsify psychoanalytic concepts, no matter how true they might be, placed psychoanalysis clearly outside the scientific field. Nevertheless, the majority of psychoanalysts agree that Cartesian doubt alone enables us to simultaneously pursue knowledge and suspend meaning. In other words, the field of science and that of truth are separate; by confusing them with each other, we are moving from science to scientism. The reference to Gödel’s theorem shows us that the scientific method and the logic of incompleteness – i.e., the logic of the singular – can be engaged in a productive dialogue.
While psychoanalysts sometimes become involved in these discussions and respond to the scientific objections made against them, it also happens that researchers from other scientific disciplines take part in the debate and attest to the validity of certain psychoanalytic concepts, e.g. Miller and Colloca’s discussion of “transference” in medicine.
As for neuroscientists properly speaking, many have also taken a position in favour of psychoanalysis. One example is the neurobiologist Francois Gonon, a world-renowned specialist in the study of dopaminergic pathways, who has warned against the hijacking of neuroscientific research by biological psychiatry hungry for scientific discoveries, and has also validated the psychoanalytic approach to phenomena that are both psychological and somatic. For the neurologist Lionel Naccache, any theory of the unconscious ignoring Freud’s theories is intellectually barbaric. The neurobiologist Gerard Edelman dedicated his book on the human mind to Freud and Darwin, whom he sees as two “intellectual pioneers” of the Western world. In one of his many books, he qualifies the hypothesis of the unconscious as scientifically “correct” and considers the Freudian mechanism of repression as “compatible” with his own theory of neuronal group selection (NGST). Speaking about his discussion of psychoanalysis and the unconscious with Jacques Monod, Edelman writes that one day, Monod declared: “I am fully aware of my motivations and entirely responsible for my actions. They are all conscious.” Edelman answered: “Let’s just say that all that Freud said can be applied to me and cannot be applied to you.” Suffice to say, the scientific debate is far from being settled.
In a work co-authored with the neurobiologist Pierre Magistretti, the psychoanalyst Francois Ansermet writes that the “concept of neuroplasticity puts in question the former opposition between the organic aetiology and psychic aetiology of mental disorders.” He adds: “Plasticity completely changes the equation, so that we begin to think of psychic causality as capable of shaping organic matter.” This research might help us finally understand what makes each human being unique. It can be argued that as a system, the neural network is compatible with singularity as understood by psychoanalysis.
Regardless of these conceptual discussions, studies on the scientific character of psychoanalysis continue, if only to illuminate the stakes of a practice increasingly more present in the mental health field, not just theoretically, but also on the level of technique and therapeutic practice.
On the level of technique, the practice of psychoanalysis requires a form of personal training established in Freud’s early writing and espoused, in one way or another, by all psychoanalytic schools. All future practitioners must be personally confronted with the framework they intend to use with others. They must not only elaborate its theoretical questions but also put to test their own ability to draw new psychic resources from it. This specific skill of the psychoanalyst has also been demonstrated by research. In an experiment published by a renowned scientific journal, the listening techniques of psychodynamic therapists was compared to that of medical students, oncologists, CBT therapists and people with an experience of childhood trauma. Using pre-recorded video testimonies, the 18 raters had to distinguish, among the recorded subjects, those who had had a childhood experience of a sibling suffering from cancer. The results clearly showed that psychoanalysts were most able to detect and identify an experience of childhood family trauma based on a person’s speech.
On the therapeutic level, other works such as those of the American researcher Jonathan Shedler have shown the efficacy of psychodynamic therapies. Shedler nevertheless points to a paradox: although the evaluations of their therapies are massively in their favour, few psychoanalysts understand the experimental procedures behind them; they are mostly unfamiliar with these methods and do not know how to refer to them. The author believes that the articles published about these experiments are in reality written for other researchers rather than psychodynamic practitioners. The latter are more concerned with the empiricism of their method than its experimental validation.
For nearly twenty years, an increasing number of studies on the psychoanalytic technique have been borrowing tools from the experimental methods, such as creating randomised patient groups, enabling them to compare the effects of different psychotherapies including transference-based psychoanalysi. On the topic of using psychodynamic therapies in the treatment of present-day mental disorders, the prestigious Lancet Psychiatry published, in 2015, a study based on 64 randomized control trials. The findings concurred with the previous meta-analyses, showing a comparable level of efficacy between psychodynamic treatment and established treatments. The authors suggest further research in this area is needed, especially in terms of treating OCD (obsessive-compulsive disorder) and PTSD (post-traumatic stress disorder). A more recent study, also published in Lancet Psychiatry, compared the efficacy of three different types of psychotherapy used to treat adolescents suffering from depression. The sample of 470 patients was randomised and divided into three groups according to the type of psychotherapy used: psychodynamic, CBT or psycho-social therapy. The symptomatic evolution did not lead to conclusions as to the superiority of any of the three approaches, but has shown that short-term psychodynamic treatment can legitimately be added to the therapeutic options offered to moderately or severely depressed adolescents.
Finally, from the perspective of theory, psychoanalytic research has produced a number of concepts which, intertwined with common thought, have now become part of everyday language. Independently of the attempts to validate them scientifically, notions such as drive, libido, slip of the tongue, repression and so on are now part of our collective thinking. They appear in the professional discourse of social work, psychiatry, education, media or in the justice system. Although this assimilation is often criticized -- either by the opponents of psychoanalysis who consider it abusive, or by its defenders who find it imprecise -- the Freudian hypothesis of the unconscious seems to be more and more readily associated with the model of human thought.
By denying the scientific status of psychoanalysis on the pretext that its treatments cannot meet the EBM criteria, we confuse the guarantee of scientificity with the statistical assessment of efficacy. For just over thirty years, psychiatry has been trying to imitate the model of evidence-based medicine, the standard of research and evaluation of therapeutic methods that now represents the consensus in medicine.In the medical field, evidence is obtained through randomized clinical trials (RCT). RCTs can establish the existence of a significant statistical difference between a control group (most often administered a placebo) and the group receiving the studied treatment. Meta-analyses are studies that consolidate and cross-check several RCTs, establishing another level of evidence. Practices based on these references are called evidence-based practices (EBP) and, in the context of medicine, evidence-based medicine (EBM).
The accusations that psychoanalysis is not scientific have to do with the fact that psychoanalytic treatments are not evaluated using EBM criteria. Although a number of studies following EBM rules have in fact shown the efficacy of psychodynamic therapies, we should still begin with a careful critique of the very model of EBM. In fact, a large body of literature has shown its limits; this is especially the case when applied to the field of psychotherapy. In principle, a research model that claims to be scientific has to be compatible with the object it studies, lest it may be invalidated as such. However, much criticism has already been voiced about the unsuitability of the EBM model to the psychotherapeutic and psychoanalytic field. These authors have shown that the evidence-based model, as a model of scientific validation of the efficacy of psychotherapies, is poorly adapted to the object it tries to assess. This has been the case for both psychotherapy (Upshur RE, VanDenKerkhof EG, GoelV, 2001; Kenny NP. 1997; Jones JW, Sagar SM. 1995; Miles A, Bentley P, Polychronis A et al. 2001) and other fields, especially when EBM seeks to impose itself as the sole model for medicine, surgery, nursing and so on. (L. Perino, 2013; A. Masquelet, 2010). Other review articles have criticised the use of EBM under these circumstances: A. M. Cohen, P. Zoë Stavri, William R. Hersh, 2004; Gail J. Mitchell et al, 1999. Their arguments concern, first of all, the “evidence” in question. Most often based on a single behavioural symptom, which can be more easily observed, these supposedly scientific studies put forth a reductive view of clinical reality (Luc Perino, 2013 et JM Thurin, 2016). On the contrary, the psychotherapeutic clinic most often shows a plurality of symptoms that interact with each other, akin to certain diseases in somatic medicine (JM Thurin, 2016; Blatt and Zuroff, 2005; Westen, Gabbard and Blavgo, 2006).
The complexity and ethics of clinical psychotherapy make it impossible to constitute samples of patients based on the six criteria required for randomised clinical trials. Specifically, the therapeutic alliance and the importance of transference are at odds with the very principle of randomization. For example, the requirement to create a (neutral) control group, as EBM dictates, is not only unacceptable from an ethical standpoint, but also logically unfeasible. On the one hand, administering a placebo-type treatment would mean that the therapist deceives a suffering patient using a ‘false’ psychotherapeutic treatment. On the other hand, the double-blind principle, also required by the RCTs, would force the psychotherapist involved in the research to provide, unknowingly, either genuine or “false” treatment (Shedler, 2015). This lack of scientific rigour in studying the efficacy of psychotherapies leads to biased results (Thurin, 2016; Shedler, 2015). Psychotherapeutic practices which are despite all trying to meet EBM criteria have to ignore the historical dimension of the symptom as it spontaneously emerges in the patient’s speech, and instead only pay attention to the binary of presence and absence (Perino, 2013).
Lastly, the quantitative criteria imposed by EBP most often conceal the importance of qualitative criteria such as the feelings of satisfaction with one’s life, well-being, improvement in one’s relationships from a social or emotional point of view, feelings of creativity, freedom of thinking and so on. When these qualitative criteria are taken into account, for example in psychotherapy outcome research, we can see significant improvements among the patients concerned (Leuzinger-Bohleber & al., 2003). In addition, a number of authors have highlighted the negative impact of EBM on the training of professionals: “As literature shows, focusing solely on specific empirically validated techniques is not enough to train efficient therapists.”
3) The Contributions of psychoanalysis and recommendations
Summary: Individual psychoanalytic training requires a years-long personal commitment, in addition to which those who wish to become psychoanalysts also have to undergo a structured training programme in one or several officially recognized associations. Regardless of their final trajectory, the person who has undergone psychoanalysis draws benefits from it in different areas of life, including their professional life. All social sectors are potentially concerned by this and can benefit, more or less explicitly, from the additional degree of discernment required by the psychoanalytic approach. In some sectors, this contribution of psychoanalysis has been recognized and certain psychoanalytic notions have become part of the professionals’ practice.
Mental health policy considers the general practitioner (GP) as an essential part of the mental health system, in terms of both screening and caring for patients, who often suffer from chronic diseases and disabilities. Indeed, the GP provides a seamless connection between the treatment of somatic disease and psychic care. As for the complex question of follow-up work, we should remember that psychoanalysts have long cooperated with GPs. Together, they created a specific framework to foster this collaboration, as well as a dedicated training: the so-called Balint group, created by the Hungarian psychiatrist and psychoanalyst Michael Balint to teach GPs how to listen to patients. Balint’s original idea was to organise workshops bringing together a training and research group composed of GPs, plus one or two psychoanalysts. The aim was to teach GPs how to be good listeners, not just to others, but also to themselves. These were not therapeutic groups: the participants’ private lives were excluded from the work. Over time, other formats were suggested, which nevertheless remained faithful to Balint’s original goal: teaching doctors how to listen to their patients without neglecting their own subjectivity.
This work gave rise to a number of concepts, deepening our understanding of the doctor-patient relationship: the “therapeutic alliance”, key to the placebo effect and to long-term care; the “drug ‘doctor’”, i.e., the idea that the doctor himself is part of the prescription; the “affects” to be taken into consideration in the doctor-patient relationship. The conceptualization initiated by Balint has now been fully recognized and continues to help advance medical psychology.
At a time when the future of medicine seems to lie in the intersection of personalised medicine, digital medicine and telemedicine, it is essential to keep in mind – as user groups increasingly incite us to do – the importance of a policy that values the human relation at the heart of the doctor-patient partnership. Thanks to their training and daily practice, psychoanalysts not only have the skills needed to play a key role in implementing this policy, but they have also endorsed it publicly, alongside major scientific and ethical figures such as Jean-Claude Ameisen or Arnold Munich. It is also noteworthy that the oldest French psychoanalytic society has been recognized as a public-interest association (Association reconnue d’utilité publique).
Some conditions of unbearable mental suffering may require institutional care (See Chapter B: Psychoanalysts and Institutional Practices). However, the staff that receives and cares for patients must be properly trained to fulfil its task. Depending on the historical era and the state of medical knowledge, the methods and resources available to psychiatric services vary significantly, lest they are purely and simply eliminated. As an atypical medical specialization constantly searching for its scientific legitimacy, psychiatry itself suffers from a lack of social recognition. Today, it is split between, on the one hand, a training mostly inspired by the dominant neuroscientific model and, on the other hand, an insatiable demand coming from the patients, their families and the public, to understand the meaning of these incomprehensible behaviours, which, for want of a better term, we call “mental disorders”. The negative effects of this confusion -- between the results of a research led by biological psychiatry and the expectations of those on the receiving end of clinical psychiatry -- have now been clearly identified. And yet, the generalization, in terms of both research and careers, of a classification system based on a superficial detection of symptoms and observable behaviours – the DSM – despite its recent criticism by its own creators; the excessive role of pharmaceutical companies in the training of future psychiatrists; the absence of plurality of therapeutic tools in psychiatry; the managerial organization of psychiatric services, which limits discussion between patients and caregivers – all these factors have contributed to psychiatry slowly abandoning its clinical and humanistic heritage. In this context, French clinicians have been interested in trainings that in other countries (Germany, Canada, Belgium, Switzerland, etc.) make space for the kinds of therapeutic work French programmes most often neglect. Some years ago, psychiatric interns themselves campaigned for their trainings to include modules on psychopathology and psychotherapy. However, working in this field involves a relational investment, which requires a personal learning process taking place outside the lecture halls and seminar rooms. This learning in the singular --i.e., “clinical” in the strict sense of the term – necessarily happens at the initiative of young psychiatrists themselves. In order to enrich their clinical experience, these practitioners often reach out to experienced psychoanalytic clinicians: to undertake “supervision” of their own practice or participate in “Balint groups”. They also sometimes decide to undergo a personal analysis.
For as long as psychiatric training maintains the current status quo, young psychiatrists will continue leaving hospital services in order to be able to work in a way that espouses the relational stakes of their practice.
On 7th July 2015, the French Research Mission on Law and Justice published a report entitled The Inner Conviction: The Effects on the Judgment of Jurors and Judges. Socio-cognitive Regulations and Subjective Involvement. This multidisciplinary report was authored by scholars in law, social psychology and psychoanalytic clinical psychology. It builds on pre-existing studies focusing on the complex questions raised by the French legal notion of conviction intime (“inner conviction”, the French equivalent of a “conviction beyond a reasonable doubt”). In order to study certain legal situations specifically, this complexity requires a multidisciplinary approach. While legal scholars have been able to define some of the rules that organise the symbolic framework of inner conviction, the qualitative approach of social psychology studies the ways in which these rules are appropriated based on social representations. The clinical psychoanalytic method shows that this symbolic framework remains empty unless a person (in the case, the judge) subjectively appropriates it; it also shows that different unconscious challenges can arise for each of the actors concerned. This research also enables us to study the notion of an “induced psychic conflict”, which reflects the judge’s double bind: to trust his own subjectivity while also challenging it. So far, only the theoretical and clinical framework of psychoanalysis has made it possible to explore this paradoxical situation, where the challenge is to reduce the discordance between the objectivation and subjectivation of the act being judged.
In addition, since the 2004 Outreau trial, the training of judges and public prosecutors at the Ecole Nationale de la Magistrature (French National School for the Judiciary) now most often include modules that, precisely, engage the trainee as an individual subject, by using pedagogical methods such as case studies or psychological techniques, e.g. psychodrama. Finally, in terms of the training of persons working in the field of criminology more generally, psychoanalysis is also increasingly part of their education.
Teacher-researchers working in the psychoanalytic orientation fully contribute to the key university missions, which are: training, conducting scientific research, spreading humanist culture via the humanities and social sciences (HSS) and international cooperation. The accreditation by the Conseil National des Universités (National Council of Universities, CNU) and the recruitment of teacher-researchers in the civil service follow the same procedure as in the case of other disciplines regulated by the CNU and present in the academia. While these scholars most often work in psychology departments, they may also be employed in other HSS sectors. Their training includes obligatory placements in institutions caring for the mentally ill (psychiatric hospitals, clinics, etc.).
Psychoanalytic teaching and research are implemented by teams organised into research units or laboratories across fifteen French universities. Since 2006, as dictated by the French Law on the Evaluation of Research and Higher Education, the scientific activities of these units are subject to evaluation procedures conducted initially by AERES (Agency for the Evaluation of Research and Higher Education) and since 2013 by HCERES (High Council for Evaluation of Research and Higher Education).
In the course of their assessment, the training and research activities of each unit are examined on the three levels of training (Bachelor’s degree, Master’s Degree, Doctorate). The number of defended doctoral theses is taken into account, as well as the quantity of scientific production: the publication of articles and volumes, organization of conferences and study days, the dissemination of scientific knowledge, etc. For the last ten years, the number of international activities of these research units has also been on the rise, attesting to the attractiveness of their work amongst foreign universities.
The growing interdisciplinarity of psychoanalytic research is also evidence of the ability of researchers and students to, on the one hand, combine their paradigms with those of other disciplines and, on the other hand, to understand the complexity of the different research questions tackled by HSS disciplines today. This research focuses on areas such as: mental suffering in the workplace (Christophe Dejours, Marie Pezé, etc.), migration (Charles-Henry Pradelles de Latour, Hervé Bentata, etc.), interculturality (François Jullien, Bertrand Piret, Françoise Hurstel, etc.), radicalization (Fethi Benslama, Denis Hirsch, etc.); the psychopathological effects of violence (Claude Balier, André Ciavaldini, etc.), same-sex parenthood (Alain Ducousso-Lacaze, Sylvie Faure-Pragier, Paul Denis, etc.), the transformations of adolescence (Philippe Gutton, François Marty, etc.), gender studies (Laurie Laufer, Laurence Kahn, Jacques André, etc.), technoscience and body “enhancement” (Marion Haza, Cristina Lindenmeyer), etc. The increasing amount of funding supporting this research testifies to the growing interest from various social partners, in both the public and private sector. The findings and concrete repercussions of this work are regularly published in renowned scientific and/or professional journals, and most often listed of their websites. In 2000, the SIUEERPP led by Pierre Fédida and Roland Gori was the first initiative to coordinate and bring together the psychoanalytic works of professors and lecturers at French and European universities.
B – Psychoanalysts and Institutional Practices
1) Historical background
Summary: In France, psychoanalysts have been working in psychiatric institutions since the first half of 20th century. Their two main contributions have been, (1) the invention of institutional psychotherapy and (2) the “désaliéniste” movement of deinstitutionalization, which inspired the French “sectorization” system implemented after WWII. Since then, French psychiatry has seen many psychoanalytic initiatives, which have all borrowed certain concepts from psychoanalytic theory, e.g., the notion of “transference”.
From WWII to the after-war period
Although the first observations of the harmful effects of psychiatric hospitals date back to the early 20th century, the notion of “institutional psychotherapy” only appeared in 1952, coined as a term by Georges Daumezon and Philippe Koechlin in the Portuguese Annals of Psychiatry. Its goal was, quite simply, to use the hospital environment as a therapeutic tool in its own right, to construct a kind of permaculture framework, in the recent sense of the word, i.e. a systems approach inspired by natural ecology. For institutional psychotherapy, the hospital environment can be a driver of transformation and development, rather than contributing to the chronicization, trauma or dehumanization that have become known, due to their devastating effects on children, as “hospitalism”. The terrible consequences of WWII on the population of French psychiatric hospitals, which saw at least 45,000 of their inmates die of starvation, equally contributed to the rise of institutional psychotherapy. We could also mention Le Guillant, the Chief Physician at the Hospital in Charité-sur-Loire, whose investigation aimed at finding the patients dispersed during wartime showed that they had in fact perfectly adapted to the region’s rural activities, putting in question the very reasons for their incarceration.
Already at the end of WWI, in his address to the Fifth International Psycho-analytical Congress in Budapest, Freud predicted that, one day, “the conscience of society will awake and remind it that the poor man should have just as much right to assistance for his mind as he now has to the life-saving help offered by surgery; […] When this happens, institutions or out-patient clinics will be started, to which analytically-trained physicians will be appointed, so that men […], women […] and children […] may be made capable, by analysis, of resistance and of efficient work. We shall then be faced by the task of adapting our technique to the new conditions. […] But, whatever form this psychotherapy for the people may take, whatever the elements out of which it is compounded, its most effective and most important ingredients will assuredly remain those borrowed from strict and untendentious psycho-analysis.” Today, Freud’s humanism continues to inspire institutional psychotherapy, attesting to the commitment of psychoanalysts to mental health and public health alike.
Initiated in France by inventive and courageous psychiatrists such as François Tosquelles and Lucien Bonnafé (Saint-Alban Hospital), Jean Oury (La Borde Clinic) or Claude Jeangirard (La Chesnaie), this movement then spread to other countries such as Spain or Italy. The deployment of institutional practices was encouraged by other theoretical perspectives: phenomenology, new psychotherapeutic techniques such as psychodrama or group therapy, or social psychiatry which emerged in the United States and several European countries in the 1950s. Active learning methods helped sustain the movement over the long-term, for example, institutional pedagogy (Fernand Oury et Raymond Fonvieille) or the well-known Freinet method.
The new generation of psychoanalysts continued to inspire institutional psychotherapy, including those who followed Lacan’s teaching, but also clinicians informed by the work of the English psychiatrist Wilfred Bion on war trauma and group activity.
During this period, state psychiatry was being developed thanks to psychoanalysis, but also transformed under the influence of communist activists such as Lucien Bonnafé, for whom mental alienation was merely an echo of social alienation.
The works of the Psychotherapy and Institutional Sociotherapy Working Group (Groupe de travail de psychothérapie et de sociothérapie institutionnelles GTPSI) dealing with the necessary development of practices and their theorization in psychiatry continue to be influential. A new complete edition of the seminars of the GTPSI (1960-1966) has recently been published.
The restructuring of the state psychiatry sector, undertaken after WWII, eventually took a quarter of a century to complete. Psychoanalysts were involved in these profound transformations, which had both a political and therapeutic impetus. On the one hand, the creation of psychiatric “sectors” replaced the previous hospital-centric model; on the other hand, the arrival of psychotropic medication such as Largactyl facilitated the work of caregivers with patients and their families.
In terms of implementing the new sector policy, the 13th arrondissement of Paris remains a reference involving psychiatrists and psychoanalysts of both national and international renown: Paul Claude Racamier, Philippe Paumelle, Jacques Azoulay, Serge Lebovici or René Diatkine. The contribution of psychoanalysis to this genuine transformation of psychiatry made it possible to transition from the old asylum conception of mental care towards a new approach, in which patients moved between several institutional structures.
By emphasizing the relational and social dimensions of care, the psychoanalytic understanding of mental disease can help us avoid, for example, reacting to the violence of a psychotic patient with more violence, which only escalates things in a counterproductive way. On the other hand, the ability of psychoanalytic practitioners to give meaning to behaviours that the rest of society considers “mad” makes it possible to undertake, together with the patient, a work of elucidation. Giving up on the former practices of segregating the “mad” and “abnormal” in favour of meaning-production enabled psychoanalysts to further develop previously abstract notions such as “negativity” or “the negative”.
As for psychotropic medications, it was used in synergy with the new focus on the dialogical dimension of outpatient care. Not only did the staff’s ability to perceive the relational foundations of their work encourage patients’ access to drug therapy, but it also contributed positively to teamwork, which in the case of sector psychiatry was always necessarily multidisciplinary.
Today it seems that neither biological psychiatry nor clinical psychiatry can live without each other. It is clear that biological discoveries have facilitated institutional practices and helped reduce both the incidence of violence and the length of hospitalizations. At the same time, the psychoanalytic tools combined with the clinical know-how of caregivers have deepened our understanding of the psychic lives and symptoms of those they care for.
Psychoanalysts in child psychiatry
When in 1944 Charles de Gaulle created the High Advisory Committee for the Family and Population (Haut Commissariat de la famille et de la population), he named as its General Secretary Georges Mauco, the founder of the Claude Bernard psycho-pedagogical centre in Paris. The staff of the centre included several psychoanalysts: Juliette Favez-Boutonnier, Françoise Dolto, Didier Anzieu and Maud Mannoni. While generally involved in the shift from adult asylum psychiatry to the humanistic “sector” system, these psychoanalysts also contributed to the creation of child psychiatry as a psychiatric field in its own right. We find a direct mark of their work in the official statues founding the French Medico-psycho-educational centres (Centres médico-psycho-pedagogiques, CMPP) since 1956. Article 16 of the Appendix XXXII to the Decree No. 63-146 (18/02/1963) stipulates, among others, that if a child’s condition requires psychoanalysis, the centre must be able to offer a suitably qualified practitioner.
The presence of psychoanalysts in institutions caring for severely disturbed children can be explained historically, as the legacy of a tradition going back to the inter-war period. For Freud, who took seriously Wordsworth’s phrase that the child is the father of the man, the idea that the adult’s destiny is in part linked to their childhood became part of the psychoanalytic theory from very early on. Treating children in order to prevent their problems from extending into adulthood thus became a priority. The first one to work analytically with children was the English analyst Melanie Klein, followed by D.W. Winnicott, a London paediatrician, whose work, inspired by psychoanalysis, allowed psychoanalysts to study, among others, the creativity and play in small children, for example the phenomenon of the “transitional object” or the “comforter”. At the same time, in France, the first psychologists, who were also physicians, were interested in child development, exploring its impediments and the means of tackling them. This focus on understanding and treating children with difficulties manifested either without directly referring to psychoanalysis (Henri Wallon); by supporting psychoanalysis while not practicing it personally (Georges Heuyer) but participating in the training of analysts (Jenny Aubry); or by undertaking the first psychoanalytic psychotherapies (Sophie Morgenstern, Francoise Dolto).
Psychoanalytic consultations therefore naturally became part of the child mental health structures that were gradually created in France over the course of 20th century: a network of CMPP (Medico-psycho-educational centres), IME (Medico-educational institutes) and CAMPS (Early Medico-Social Intervention Centres). For example, the Claparede Institute, created in 1949 by the psychoanalyst and member of the SPP Henri Suguet, was financed, starting from 1956, as a CMPP. Today, this Institute continues to pursue its mission of “safeguarding children and adolescents”.
The specific case of day-care hospitals for children (Hôpital de jour, HDJ) has to do with their triple function: removing the children concerned from the child and adolescent psychiatry services, maintaining their relationships with their environment (family, school) and helping them give meaning to the symptoms that interfere with these relationships. The specificity of these outpatient structures, which can provide part-time care for children who are thus able to continue normal schooling, is that they combine psychological care with education and pedagogical work. Attending to children’s psychological problems in these types of structures makes it possible to adopt a multidisciplinary approach and meet the complexities of child development via a range of complementary professional skills.
Created by Maud Mannoni and her team in 1969, at a time when children’s issues and psychic disorders were still a reason for their exclusion from the normal channels, the Bonneuil Experimental School was able to function, for six entire years, without any state funding. The network sustaining it was initially constituted of the friends and families of the children cared for. It rapidly grew to include professionals and volunteers, as well as students interested in this innovative experience. Today, the goal of this school “unlike others” is still to offer a living space for children who would otherwise remain excluded from all educational or academic channels. The institution is also involved in research, specifically concerning severe mental disorders such as psychosis. Since its founding, its theoretical orientation has remained psychoanalytic.
These types of innovative facilities led to the creation of today’s Maisons des adolescents [Adolescent centres], such as La maison Solenn directed by Professor Marie-Roso Moro, or the Crisis centres. In the lives of the children and young people treated here, these spaces provide a continuity between their family environment and the sphere of mental health care. They also prevent a premature and stigmatising diagnostic labelling, the detrimental rather than beneficial effects of which have been shown by studies.
2) Current situation
Summary: Since the beginning of 21st century, the place of psychoanalysis in the mental health field has changed, mostly to its disadvantage, for both good and bad reasons. Though we shall leave a detailed appraisal of its actions to historians, we can identify several key points. Some explain the unfavourable aspects of its actions, others its favourable, innovative or event avant-garde features.
Conceptual and methodological differences
Psychoanalysts, who have been widely involved in psychiatric institutions, especially since the creation of the sector system, have always worked towards a humanistic psychiatry, when it comes to receiving or supporting people in deep psychological distress. Still, they have also at times wrongly assumed positions of knowledge and mastery, or even dominance, turning a deaf ear to their critics. They were thus confronted with the growing influence of new approaches coming from other mental-health and psychiatric paradigms but failed to either properly ally with them or oppose them. For example, the neurosciences, whose tools – such as brain imaging – are close to those of medicine, have managed to reorient psychiatric practice towards a more biological approach. Faced with the success of neuroscientific methods, psychoanalytic conceptions seem to have lost, at least momentarily, the interest of caregivers and policy-makers in the psychic realities of patients. Moreover, psychiatry as a whole has been slowly turning away from the experience and knowledge of clinical psychopathology.
The context in which these changes have occurred is that of the rigid application of the methods of evidence-based medicine in psychiatry. These methods have helped deepen the gap between, on the one hand, the true object of psychiatry as a medical specialization, i.e., the psychic suffering of human beings, who as a result are excluded from social relations, and, on the other hand, the means implemented to appease this suffering. By replacing this naturally relational object with a new and incredibly complex object, the human brain, neuroscientists have dethroned the intersubjective conception of psychic care in favour of its understanding as something standardisable and quantifiable. In addition, the growing influence of the U.S. psychiatric diagnostic system, the DSM (Diagnostic and Statistical Manual of Mental Disorders), follows the same logic: no longer trying to understand humans as relational beings, it instead follows a fragmentary, symptom-by-symptom approach.
The current situation therefore brings into focus two contradictory conceptions of psychiatric care: one, a framework of encounter and care for the mentally ill, partially inherited from the beginnings of psychoanalysis in 20th century; two, a system of classifying individuals with psychic problems, which has been created out of economic necessity. The first conception, while freely admitting its gradual loss of influence, nevertheless continues to enjoy the trust of some of those delivering this care in the establishments where they work. The other, based on the methods of somatic medicine, carries out research that aims to either identify the areas of the body (mostly the brain) responsible for psychiatric symptoms or establish the superiority of its own methods over those previously used. These two currents, which do not manage to influence each other, continue to publish the results of their work separately in renowned scientific journals, which, though widely accessible,,are rarely read by the general public or political decision-makers.
However, despite all this, a third way seems to be emerging. Mostly at the initiative of psychiatric users, mutual support groups have been created together with discussion groups, social clubs, etc. Although these associations are often trying to make up for the shortcomings of psychiatric institutions, they cannot be substituted for the sectors’ therapeutic mission. Some may for example deal with housing issues, helping integrate patients socially. Yet it is not enough to offer turnkey homes to schizophrenic patients; we must also be able to support them, in a professional manner, to gradually appropriate their new living space.
Evaluation of the psychiatric sector
In line with those of other hospital sectors (surgery, obstetrics, etc.), the average length of stay (ALS) in a psychiatric hospital decreased from 105.7 days in 1980 to 28.9 days in 2011. This may seem satisfactory from a financial point of view, yet this remarkable development has produced an improvement in neither the living conditions of the patients nor the working conditions of the staff. In 2013, the report of the French Government’s Mission for Mental Health and the Future of Psychiatry (the so-called Robiliard Report)pointed out that the results of the efforts at renovating psychiatric services have been disappointing to say the least. The report cites the insufficiency of resources, both material and human, specifically the number of vacant posts in psychiatry and the gradual disappearance of specialised psychiatric nurses. At the end of the report, the measures suggested and the recommendations to improve the situation are presented as a list of 30 propositions. Psychoanalytically-oriented clinicians are in favour of many of these propositions and have since been working to implement them in the places where they are in charge: a revalorization of the psychiatric sector (No 6, 7, 8); abandoning coercion as a first-line approach (No 15); recognizing, as a first resort, the crucial role of clinical psychologists, nurses and GPs (No 25); new emphasis on the training of psychiatric nurses (No 26); encouraging interdisciplinarity (No 29); developing mental illness research (No 27).
In psychiatry as elsewhere, violence is multifactorial and should be studied from a variety of perspectives. However, clinical experience shows that in this medical specialization, the reduction of violence is generally achieved by allowing the people involved to talk to each other, as it is the case in most situations of conflict.
By slowly taking up its position in the institutional landscape, psychoanalytic research attests to the relevancy of its methodology and the specificity of its objects of study. By exploring group dynamics, psychoanalysts have developed skills that can now be put to use in different contexts: social work, health-care, psychiatry, schooling and education, the legal and even penitentiary system (see above, Chapter A).
Also, French university laboratories with a psychoanalytic orientation have contributed to research that is directly inspired by current national affairs.
Just two examples:
A study of a cohort constituted after the terrorist attacks of 2015:
Research on radicalization, the setting up of an SIG bringing together researchers from two universities (Nice and Paris-Diderot) and the creation of the Centre for the Study of Radicalizations and their Treatments:
Finally, concrete social changes have also been the object of assessment and scientific enquiry, for example the current changes in the institution of the family, which are studied by psychoanalytic researchers in collaboration with other humanities scholars. These studies are increasingly drawing interest from the general public, other humanities disciplines,, and public authorities.
3) Recommendations and innovative practices
Summary: Over the past decades, psychoanalysts have been adapting their practices to new forms of expressing psychological distress. While the original “talking cure” has evolved, the current modalities of listening to mental suffering still give speech a predominant place. The effects of listening to the patient’s singularity have been attracting attention from a growing number of psychiatric institutions, practitioners and researchers.
Giving speech its rightful place
The teaching and practice of psychoanalysis have developed, slowly but surely, in many countries over the world. While initially represented by a single institution, the International Psychoanalytical Association (IPA), psychoanalysts have since widened the range of their theoretical models and formed new groups, not only based on cultural and historical specificities, but also along doctrinal and theoretical lines. This adaptability of clinicians to the changing conditions of teaching and practicing psychoanalysis has encouraged their reactiveness, especially during the institutional transformations that have occurred since the mid-20th century. In France, for example, 1979 marks the first opening of a maison verte, a drop-in centre for very small children and their carers created by Francoise Dolto; since then, the network of similar facilitieshas continued to grow. These psychoanalytically-inspired spaces function outside the medical model, particularly in terms of funding. They are open to parents and their children aged 0-4 and can prevent the appearance of early relational and/or functional problems. This form of support seems to be especially useful during key stages of the parent-child relationship, such as breastfeeding, weaning or learning how to walk, during the first separations or the arrival of a sibling. Over the last forty years, similar structures have appeared throughout Europe, in Canada, Latin America, in Israel, Russia, etc. The effectiveness of these preventative mental health facilities is regularly assessed. In December 2017, the proceedings of a conference called Prevention, did you say prevention? were published, focusing on the experience of maisons vertes in this area.
The impetus for one of the most significant transformations of the mental health field came from the psychiatric users’ movement. Users have in fact gradually become partners to mental health professionals, not on the basis of their theoretical or technical competence, but due to the commonality of their personal experiences. Psychoanalysts were not the initiators of this movement, but they often became actively allied with it, recognizing that in the world of psychiatry, giving so much space to patients’ speech showed an unprecedented degree of openness. As an example, a team of psychoanalysts at the Strasbourg Teaching Hospital created, in collaboration with the National Union of the Friends and Families of Mentally Ill (Union nationale de familles et amis de personnes malades et/ou handicapées psychiques, UNAFAM) a framework for the group treatment of “bipolar” patients in Alsace. Linked to a training course for medical and psychology students at the University of Strasbourg, this innovative system was inspired by the principles of “large groups” or “community meetings” of Maxwell Jones, Wilfred Bion and Siegmund Foulkes.
Psychiatric users, who join together to form various associations, have been leading this struggle in the name of dignity and full citizenship. Psychoanalysts recognize their own values in this struggle, if only in reference to the very principle of psychoanalytic treatment, to which each psychoanalyst must first submit himself, before being able to offer it to others.
The therapeutic partnership with psychiatric users or user associations can sometimes bring psychoanalysts closer to the behaviourist or education models of treatment and they may even intervene in them at times. However, the key difference between psychoanalysis and education-centred models has to do with the concept of “transference”, which in psychoanalytic work must be handled and interpreted in a particular way. In keeping with the very foundations of psychoanalysis, this cooperation must therefore give the patient’s speech its full importance, even if the latter breaks away from the therapist’s own modes of comprehension or logic. In such situations, making the hypothesis of the unconscious means that the therapist must remain open, free of prejudice and able to hear in the patient’s speech other things than just the confirmation of his own views.
After having long considered mental disorders from an intrapsychic perspective, psychoanalysis and those who practice it have also taken into account their “inter-psychic”, i.e., relational dimensions, in order to study them more deeply. The therapeutic situation is therefore no longer that of an analyst who “knows” and decides, on behalf of the “patient”, what is in the latter’s best interest, but of two human subjects who are present and dealing with a situation that should evolve towards a greater well-being of the person suffering.
For example, in the treatment of autists, the importance of a dialogue with the people around the autistic person has shown itself in a different light: the problems of interaction between the patient and his family are no longer approached in terms of causality but considered as random variables which can be acted on.
While this change has led to significant transformations in child psychiatry, it has also had important repercussion on the treatment of adults. Given the different view on the role of the family environment, psychotic states are no longer seen as pathologies of the family, but as a form of suffering that can weigh heavily on the family. By working towards a change in family relations, hitherto altered by a guilt-inducing etiological model, this new perspective helps resolve previously inextricable situations.
The example of auditory hallucinations can help us understand the beneficial effects of supporting the speech of psychiatric patients. The “voice-hearers” movement first appeared just a few years ago, led by patients’ efforts to come together and share their individual experience. In the 1990s, it became established internationally by setting up the Hearing Voices Network, now present in most countries worldwide, including many cities in France. Given that voice-hearing is not, on its own, a symptom of mental disease, the people associating in these networks have a sole common objective: to promote an approach to voice-hearing and other uncommon perceptions that is respectful of the people concerned and their expertise.
The role of singularity
Being part of a group of people who suffer from the same mental symptom is perfectly compatible with the case-by-case approach of psychoanalytic treatment. Working with a group of symptomatically homogeneous patients also satisfies the methodological criteria of clinical research, specifically when studying the efficacy of medications. However, setting up these types of groups does not make the subjectivity of each of their members disappear. It is true that the development of RDBPCT follows the objective of neutralising not just the subjectivity of the patient on whom the studied drug is tested, but also that of the person prescribing it. As for the use of these trials, we should remember that while organic symptoms lend themselves fairly easily to the constitution of homogeneous groups, in the case of psychiatric symptoms any such homogeneity is completely illusory. At the same time, subjectivity plays a key role in the coming together of those suffering from the same symptoms: hyperactivity, bipolar disorder, depression, etc. (see above).
In the context of biological psychiatry, which has become epistemologically indefensible, the position of psychoanalysis in this matter has not changed. Again, the notion of transference serves as an epistemological compass leading the analyst’s work. Contrary to biological psychiatry, which struggles to uniformize the description of an ever-growing number of symptoms, psychoanalysis continues its work of “meaning-making”. While psychiatric practice increasingly relies on “off-the-peg” psychological solutions, psychoanalytic practice remains focused on a “tailor-made” approach to psychic suffering. In the institutional context, actions are taken on a case-by-case basis, such as individual psychotherapies with psychotic patients, individual listening in group work, meditation workshops, etc. and are based on the hypothesis of the unconscious and on transference, which remain the markers of subjectivity psychoanalytic clinicians take extremely seriously. As for psychiatric practitioners, including non-psychoanalysts, who use psychoanalytic concepts in their work, they too constantly enrich the institutional experience. Some of these initiatives, such as “therapy clubs” (clubs thérapeutiques) are now also part of the French Public Health Code.
Until 1968, French psychiatry was associated with neurology. Its relatively recent autonomy is in part the reason why biological psychiatry continues to exert a major influence on its institutional practices and regulatory frameworks. However, born of the alienist tradition of the early 20th century, clinical psychiatry remains tied to the reference framework of psychopathology created by this tradition and, post-WWII, to the indelible mark left by psychoanalysts on the French sectorization system, specifically in terms of its social and relational aspects.
C – Psychoanalysis, Children and Youth
1) Historical background
Summary: The changing social representations of the child are a recent phenomenon. In just over a century, the society’s view on children has undergone a profound change. The new knowledge brought by psychoanalysis during this period largely contributed to this transformation. The notion of “psycho-sexual development” made it possible to understand certain previously inexplicable childhood behaviours. These discoveries have both helped illuminate and drive the complex changes currently transforming the relationships between adults and children.
The work of historians post-1960 has shown that today’s understanding of the concept of the child -- i.e., as a person in his own right, endowed with reason and intelligence -- only dates back to the late 19th century. However, this profound change had already began in the late 18th century, when the child, still seen as insignificant in terms of truth and reason and at best considered a kind of miniature adult, became the model expected to free humanity of its prejudice and corruption.
At the beginning of 19th century, the first works of educators, such as Edouard Séguin’s 1846 Traitement moral, hygiene et education des idiots (“Mental Treatment, Hygiene and Education of idiot”), or physicians like Jean Itard (1774-1838), the precursor of child psychiatry who treated Victor of Aveyron, showed that innovative and well-adapted education methods could help children previously qualified as ‘idiots’, ‘retarded’ or ‘savage’ make progress and access learning and work. These methods could then be expanded to reach many more children (see especially the early 20th-century works of Maria Montessori). Unfortunately, the medical and educational approaches competed with each other for influence. At the end of 19th century, the neurologist Désiré-Magloire Bourneville (1840-1909) proposed an integrative model combining care and education but was later criticised by his successors (Alfred Binet and Théodore Simon).
The category of “mentally unstable children” (enfants instables) emerged from the political debate following the compulsory education reforms of Jules Ferry (1882). These reforms also put physicians in charge of the new pupils who either failed or refused to comply with school discipline. In 1899, the Free Society for the Psychological Study of Children (Société Libre pour l’Étude Psychologique de l’Enfant) was thus created as a matter of urgency: after multiple “investigations”, Binet and Simon declared these children “ill” rather than “little rascals”. They described them essentially in terms of educational and intellectual deficiencies due to “family brutality”. The aim was to determine which of these children could be educated and which could not. The former would attend special classes; the latter, considered uneducable, were rejected from schools and sent back to their families, asylums or even juvenile prisons. In early 20th century, the first effects of the generalization of compulsory public schooling, combined with the new understanding of child development coming from psychoanalysis, revived the interest in children and their education. The child was no longer seen as a being of pure need, one that must be removed from the animal world or sin, or a miniature adult who should be made to grow up as quickly as possible.
The decline of religion and of politics as truth led to a certain withdrawal into the intimate sphere of the family, despite its metamorphoses and successive decompositions and re-compositions. The child therefore appeared as a kind of “glue” holding the family together, while the permanence of the marital couple grew more uncertain. In literally becoming the family’s treasure, the child not only embodied the parental ideals and expectations, but the collapse of the religious frameworks also led him to incarnate the hopes of immortality.
The youth of psychoanalysis
During this same time, a very different understanding of children and their problems was studied by Freud, based on the model of the “psychic apparatus” already described earlier in this report (See Chapter A, Psychoanalysis and Scientific Criteria: “Scientific foundations”). From its very beginnings, psychoanalysis recognized that each child is a singular subject whose psychic life is much more complex than that of a simple organism adapting to its environment. Using the concept of the “drive”, Freud describes the child, as early as in 1905, as a human being whose psychosexual identity is built gradually and whose early “sexual theories” fuel his desire for knowledge and personal inventiveness. Like the adult, the child also has to deal with psychic pain and interpersonal turmoil (jealousy, envy, anger, love, hate, etc.). In the case of “Little Hans”, reported by Freud, the little boy struggles with an animal phobia, but is relieved of his symptoms once they have been analysed. In the context of a transference, it was possible to lift repression and interpret the child’s unconscious formations by linking them to his relationship with his parents.
The psychoanalytic theory of infantile sexuality undermined the myth of childhood purity. In early 20th century Vienna, its discovery caused a shock to the medical field and the general public alike. The revelations about children’s abilities to elaborate their drives, to redirect and displace them, as well as their capacities of sublimation remain a major clinical and theoretical contribution. In the field of caring for infants and children, today’s clinicians are generally familiar with the psychosexual development stages described by Freud as taking place from 0-6 years. Likewise, after the age of six, during the so-called latency stage, sexuality is of lesser importance and the child’s desire to learn and integrate social norms is foregrounded. However, the drives do not disappear during this time and some of their manifestations are carried over into the classroom. Freud’s students verified and developed his ideas through child psychoanalysis: Melanie Klein, Anna Freud or D.W. Winnicott. As we have said earlier (See Chapter B, Psychoanalysis and Institutional Practices: “Psychoanalysts in child psychiatry”),Melanie Klein invented a method which took into account the importance of the “early stages of the Oedipal complex”, of “archaic” drives and very early phenomena linked to, especially, the projection of inner psychic conflict onto others. Klein’s teaching had considerable influence in both Europe and Argentina, where psychoanalysis also became widespread. Like Anna Freud, she used play as a technique to communicate with the child’s psychic realities.
In London, D.W. Winnicott, a paediatrician and psychoanalyst, combined his careful observation of children with psychoanalytic experience to show the importance of primary care in the development and establishment of the child’s vital feeling of a psychic continuity of existence. He founded his idea on a phenomenon well known to parents: the “comforter”, to which most children become strongly attached. His theory shows, in highly original ways, that this object is the product of a “transitional” area and lies at the origins of children’s creativity.
Klein’s and Winnicott’s work had an influence on the theory of the French psychiatrist and psychoanalyst Jacques Lacan, who developed the concept of the “mirror stage” to understand the process of structuration of the subject and his psychic agencies based on the three dimensions of the real, the imaginary and the symbolic. Psychoanalysis had a strong influence on the emerging field of education science, showing that children’s appetence for knowledge stems and develops from their sexual curiosity. It also showed that the wish to learn depends on the transference investment in the person of the teacher. Learning is thus not simply a question of operational performance, but also has to do with desire and its possible impediments. Taking these different aspects into account made it possible to understand certain learning difficulties, later theorized by psychoanalytically-inspired psychopedagogy.
As part of the post-WWII social reconstruction movement, French psychoanalysts were involved in and greatly contributed to the creation of new mental health care facilities, following the traumas of war and of children’s separation from their families. Based on his work with these children, the Hungarian psychiatrist René Spitz, associated with the Paris Psychoanalytic Society (SPP), coined the notion of “hospitalism” or “anaclitic depression”, showing the importance of early attachment and the risks inherent in its breakdown and in lasting deprivation.
Immediately after the war, psychoanalysts and psychoanalytically trained educators created the first Medico-psycho-educational centres (CMPP), as described in Chapter B of this report (see Psychoanalysts and Institutional Practices). The first among these, the Claude Bernard Centre was founded in Paris in 1946, under the auspices of General De Gaulle, by Georges Mauco and Dr André Berge. Its staff included major psychoanalytic figures such as Françoise Dolto, René Diatkine, Serge Lebovici, Maud Mannoni and Didier Anzieu. Other similar facilities subsequently opened throughout France, for example the centre directed by Juliette Favez-Boutonnier in Strasbourg. Still today, the Decree No. 63-146 of 18th February 1963 defining the functioning of the CMPP remains the only legal text directly citing psychoanalysis as a form of care and explains that if a child’s condition requires analysis, the institution must be able to provide a qualified professional. Psychoanalysts therefore contributed to the development of child psychiatry and psychoanalytic consultations were present in most of the facilities caring for children gradually set up in France. Georges Heuyer, the founder of French child psychiatry, brought psychoanalysts into his hospital service as early as in 1925: first in the person of Eugénie Sokolnika, then Sophie Morgenstern and later Françoise Dolto and Jenny Aubry.
During the second half of 20th century, psychoanalysts actively participated in the creation of many care facilities, following the paradigm opened up by institutional psychotherapy and the sectorization policy, both in health care (in the child and youth psychiatry sectors) and in the medico-social field, specifically in day-care hospitals, and medico-educational institutes. The difficulties and mental suffering of children and adolescents were thus cared for by highly structured and adapted facilities offering interdisciplinary approach that combined care, education and training without separating the child or young person from his natural environment, thus avoiding the previous segregation and exclusion. The Bonneuil Experimental School, created in 1969 by Maud Mannoni and her team, was able to function for six years without any public funding, as highlighted in Chapter B, Psychoanalysts and institutional practices. Child psychiatrists and psychoanalysts such as René Diatkine, Serge Lebovici or Michel Soulé made a significant contribution to the setting up of various care facilities (especially in the 13th and 14th arrondissements of Paris). Lebovici and Soulé also authored a textbook of child and adolescent psychiatry, which remains an unsurpassed reference in the encounter between psychiatry and psychoanalysis. They were also the creators of psychoanalytic psychodrama for children. Roger Misès became the Director of The Foundation Vallée Hospital Centre (created by Bourneville at the end of 19thcentury) building on the knowledge of psychoanalysis and institutional psychotherapy.
Psychoanalysts were involved in the setting up of the child and adolescent psychiatry sectors, which included hospital facilities, especially in terms of liaising with general hospitals, of early and perinatal care, as well as outpatient structures such as medico-psychological centres (CMP), part-time therapeutic centres (centres d'accueil thérapeutiques à temps partiel, CATTP) or, more recently, adolescent centres [maisons d’adolescents]. Highly diversified, these frameworks are free and open to the public; they receive both children and their parents. They maintain relationships with schools and other social partners. In order to provide a comprehensive therapeutic approach, they employ a multidisciplinary team including speech therapists, movement therapists, nurses, special-needs educators, etc. Today, these facilities represent an invaluable national asset and are the envy of many foreign countries.
The year 1955 saw the creation of new psychological support centres for students (Bureau d’Aide Psychologique Universitaire, BAPU), which were anonymous and free of charge and were set up and ran by psychoanalysts. Today, sixteen of these centres are still operating in France and are now also open to secondary school students.
To conclude this review, let us again mention the great voice of French psychoanalysis, Françoise Dolto, whose exceptional clinical acumen and pedagogical talent left a mark on professionals and families alike. A renowned paediatrician and psychoanalyst, for two years (1976-1978) Dolto also spoke to the French public multiple times per week on the France-Inter radio programme Lorsque l’enfant paraît (“When the Child Appears”), answering questions from listeners. She was the creator of a new type of framework for very young children and their parents, the so-called Maison vertes, and her contributions to analytical theory continue to enrich today’s work in nurseries and kindergartens.
Today, all the institutions described in this report and many others remain functional and demonstrate their efficacy and humanity. In what constitutes a genuine public service of listening and supporting the mental pain of children and their families, psychoanalysis remains a fundamental, non-exclusive reference. And despite their practical and theoretical differences, all psychoanalytically-oriented child clinicians continue to develop these structures, a firm fixture of 21st century.
2) Current situation
Summary: The classification systems created in 20th century to describe and treat the psychological difficulties of children use a normative medical model. However, these difficulties exist in a social context in which children are subject to contradictory pressures. Certain studies, in line with the new biological orientation in paediatrics, have been controversial. The problems linked to the treatment of autism have been part of these debates. The positions taken by psychoanalysts on these matters are both self-critical, measured and constructive. Different initiatives within the child and adolescent sector, such as the creation of the mother-child units, correspond to the empirical validation of psychoanalytic notions. Strengthening the presence of psychoanalysts in this sector can improve its efficacy.
The child and his “problems”
Since the early 1980s, a new understanding of the child began to emerge, centred around the notion of “disorder”, so that we could indeed speak about the manufacturing of a “disordered child”. The designation of various “disorders” to characterise the difficulties of children, derived from the American classificatory system, the DSM, introduced a new paradigm, one that reverberates on the subjectivity of each child and young person, without sparing the adults. Its designations de facto question both the clinical realities observed and the current status of the child and its paradoxes, from both legal and social standpoint.
On 20th November 1989, the International Convention on the Rights of the Child was adopted by all countries except Somalia and the United States. It protects the child’s fundamental civil, economic, political, social and cultural rights. It has led to a new consideration for children as persons, their aspirations, needs, health and well-being. In addition, certain imperatives must now be respected in terms of socialization, education and pedagogy, as well as in the constitution and organization of families, no matter how heterogeneous (traditional, same-sex, single-parent or blended families) they may be.
However, at the same time, this tendency to define and endorse the child’s legal status as a person and subject of law has led to various excesses. First, it reinforces the present-day tendency to treat and systematize the care for each child as a “typical” or “normal” child, in line with the current scientific standards, both neurobiological and statistical. Second, once the child becomes subject to various cultural, ethical, ideological, advertising, consumer and financial interests, he finds himself trapped by the prevailing social ideals, to the detriment of the singularity and originality of his own childhood. Finally, while trying to define an ever-expanding range of children’s rights, the society is slowly bringing the child closer to the status of an ordinary citizen, forgetting the natural immaturity characteristic of this stage in life.
This paradox occupies the daily practice of child clinicians and professionals who are institutionally in charge of children: educators, teachers, legal stakeholders, etc. While children are regularly represented as the victims of abuse or suffering from various “disorders”, they are also asked to take on an ever-growing burden of responsibility. The current debates on the legal age of criminal responsibility or the age of consent attest to the issues that must be taken into account and the logical temporality of childhood and adolescence that should be respected.
A working group created in March 2017 by the then-Minister of Families Laurence Rossignol was asked to improve the protection of minors against internet pornography. However, despite the recently passed law that further suppresses the publication of sexual images, the lawmakers’ difficulties in effectively curbing the massive exposure of children and adolescents to violent and pornographic images were striking. And yet, research has clearly shown that these images do interfere with the psychic elaboration of sexuality. A scientific report published in 2017 and funded by the Law and Justice Mission in collaboration with clinical psychologists and psychoanalysts shows the role such images can play in the identity-construction of young people.
In general, how do we teach children and young people to handle the availability of consumer goods and increasingly powerful technological tools, which create the illusion of an ever-growing autonomy for even very young children, as well as of a greater ability to express oneself via social networks?
Within the dynamics that the current social and societal transformation create for all generations, parents feel overwhelmed by the subjective effects of these changes. While they complain about them and suffer from them, they also have a stake in them and are immersed in the ambient discourses.
Often referring to psychoanalysis, practitioners working with children and their families regularly alert the authorities and general public to the undeniable risks that these changes and their extremes can create. In their work, they emphasize interdisciplinarity, the complementarity of therapeutic methods and the neuroscientific discoveries. Their approach is in line with the recommendations of the most recent Child Psychiatry Convention (Etats généraux de la pédopsychiatrie), which took place in April 2014 in Paris. Professionals working with children heed the orientations set forth by the Government’s mental health policy. Specifically, they support the notion of the free choice of care and the mutualisation of care resources in order to enable a better functional synergy between practitioners who work on a case-by-case basis. Only on these conditions can we create a climate of trust between all those involved, which remains the main guarantee for any genuinely inter-connected therapeutic work to happen.
In the 2000s, this trust was undermined by two specific events. The first was the publication, in 2003, of an INSERM report entitled Mental Disorders. Detection and Prevention in Children and Adolescents (Troubles mentaux. Dépistage et prévention chez l’enfant et l’adolescent). In its introduction, the authors argued that in France one child in eight (12%) suffered from a mental disorder. They also predicted that by 2020, this figure would have risen to 50%, in line with global trends. The second event was another INSERM publication, in 2005, entitled: Behavioural disorders in children and adolescents (Trouble des conduites chez l’enfant et l’adolescent). This collective study caused great indignation, specifically among clinicians working with young children, but also among parents and some teachers. It led to a petition signed by 300,000 people and the creation of a collective of practitioners called Ban poor conduct reports for three-year-olds (Pas de zéro de conduite pour les enfants de 3 ans).
Despite these well-founded criticisms and the reservations articulated, in the report itself, by Professor Daniel Widlöcher, a renowned psychoanalyst, the names of these so-called “disorders” have since filtered into professional discourse, both written and spoken, as well as everyday language. This devalues the very notion of diagnosis, because everyone feels entitled to make use of these designations simply based on personal interpretation. Already at nursery age and despite the complexity of working with children clinically (in other words, on a case-by-case basis), these diagnostic labels are distributed inaccurately and carelessly. This is added to the initiatives of certain institutions such as National Education, which encourage teachers to diagnose, for example ADHD, contrary to its own regulation. These diagnoses thus eventually gain a foothold and in less than twenty years their terminology has managed to infiltrate the surrounding social discourses, especially under the influence of highly active pressure groups, e.g. certain parent associations, themselves subject to academic pressures. Today, this new “hunt” for child “disorders” has become a genuine social phenomenon, which can be observed via the different procedures and protocols that have now been made obligatory in many institutions. Their aim seems to be to reduce the child’s manifestations to a simple set of signs. The behavioural sign is the most obvious: it is first isolated (defiance, attention, agitation, etc.) and then defined as a category: ODD (Opposition defiant disorder), ADHD (Attention Deficit Hyperactivity Disorder), etc. Yet how can we accept reducing the clinical richness and complexity of children to a handful of diagnoses?
The notion of the disorder is derived from the American classification system, the DSM, which uses it in the sense of a dysfunction, a deviation from the norm. Each deviant manifestation is statistically calculated, enabling to measure its distance from the norm, but also its deviation from the ideological and moral values of the American culture. Today, such are the foundations of the categorization of mental health. We could say that the child of the DSM is the child of deficiency and disability, who must be medicalised in order to bring him closer to the norm. The clinical coherence and validity of the DSM categories are uncertain, as recognized by one of its main creators, Allen Frances, who has spoken widely about the risks of over-diagnosis contained in its 5th version. For children, this over-diagnosis has already led to the phenomenon of false epidemics, which go hand in hand with a massive over-prescription of psychiatric medication.
In the field, these attempts at objectivizing children make the everyday clinical work more and more difficult, preventing clinicians from being able to detect illness as understood by child psychiatry. It also encourages the labelling of certain behaviours as deviant and this process leads to the expansion of the field of disability. In fact, every child with academic difficulties is now likely to acquire a “MDPH” (Departmental Centres for Disabled Persons, Maisons départementales des personnes handicapées) file, which urges those around him to “compensate” for the so-called disability in an effort to “integrate” the child. In these conditions, the child, whose singularity has been effaced, is reduced to a mere specimen of a population and treated as a stereotype.
These practices have already led to misdiagnosis and false positives which clog up medical consultations and penalise those children whose genuine pathologies deserve all our attention. Like in CMPs and CMPPs, each specific situation should be evaluated by an interdisciplinary team, which approaches the child as a subject in his own right. This type of care considers the child’s environment but also his history, enabling us to distinguish between a genuine pathological symptom and a transient difficulty. On this level, autism raises many complex problems.
The question of autism
The criticisms of the psychoanalytic approach to autism echo the distress, suffering and disappointed hopes of many families. Since the early 2000, psychoanalysis has been the target of virulent attacks regarding its approach to treating autism, seen as ineffective for children and guilt-inducing for parents.
Today, it is important to remember that our understanding of autism has changed. For example, it is now an established fact that there are a number of different clinical forms of autism, which require different therapeutic responses. Psychoanalysts have also evolved in their approach, not only theoretically, by giving up on the model of a specifically autistic “structure”, but also in terms of the clinical methods used when working with autists. In addition, they have produced sophisticated studies, such as the PREAUT early sign study, which looks at the risks of developing autism among children under 12 months of age.
Some parent groups continue to take psychoanalysis as their target. Their criticisms concern in particular the psychiatric treatment of autism and the existence of a psychic reality which they question. As for those psychoanalysts who work with autists, they have not only espoused the knowledge produced by other disciplines such as cognitivism, the neurosciences or genetics, but they also work together with other professionals and of course the parents. This new conception of autism is apparent in the works produced by the International Coordination between Psychotherapists and Psychoanalysts taking care of Autists (Coordination Internationale entre Psychothérapeutes Psychanalystes s’occupant de personnes avec Autisme, CIPPA), which was founded by the French psychoanalyst and specialist in working with autistic children Geneviève Haag.
Analytically-trained therapists who are involved in caring for autists today, are working in different care institutions alongside parents and other professionals: speech therapists, movement therapists, special-needs educators and teachers. They support the project of helping integrate autists, whenever possible, in normal environments, especially in schools.
Therefore, alongside and complementing the approaches developed by other orientations, psychoanalysts have produced expertise and efficient practices in the treatment of various autistic issues, such as autistic anxieties, the construction of body image, the emergence of language and the development of interhuman and social relationships. This psychoanalytic know-how is now publicly claimed by hospital practitioners who implement it every day, for example Professor Dr Bernard Golse.
Psychoanalytic work at key moments in a subject’s life
Certain life stages, specifically the periods of identity-construction, can at times expose the individual to intense psychic pressure. During these moments, the presence and interventions of psychoanalysts can help the person make sense of these transitions and ease their pain by sharing it with others.
For many years, the psychoanalytic work in the field of perinatal care (i.e., the care for women and a foetus or a new-born before, during and after delivery) have regularly attested to the usefulness of their listening to both the people concerned and their families. For example, in the writing of Monique Bydlowski, we find a detailed account of how psychoanalysis can contribute to the work in a public hospital maternity unit. In the larger field of child mental health, the research carried out by Sophie Marinopoulos is often featured in high-quality publications. Her interest in the phenomenon of pregnancy denial also enables us to study the otherwise under-researched question of maternal infanticide.
The place and involvement of psychoanalysts in this medical field have generally not been sufficiently recognized, despite their regular efforts at presenting their work. The delicate clinic of neonatal paediatricians with new-born babiesjustifies the need to work together with other teams dealing with the psychic lives of mothers. The creation of “mother and baby” hospital units attests to the authorities’ new awareness regarding the need to put into practice Winnicott’s aphorism that a baby alone does not exist.
On the local level, this new awareness led to, for example, the creation, in 2013, of the new Mother-Child Laennec Medical Division at the Necker-Enfants Malades Hospital. In 2017, the “European Days for Mother-Baby Units” were organised by the Paris Psychiatry & Neuroscience Regional Hospital Group (Groupement Hospitalier de Territoire Paris Psychiatrie & Neurosciences). The goal of these study days, both theoretical and practical, was to bring together the different themes around childbirth, seen from a variety of developmental, psychoanalytic and systemic perspectives.
Schooling is a key stage in child development and has been studied by child psychoanalysis in terms of the psychological issues it can trigger. Teachers can of course identify that a child has certain difficulties, for example in learning how to read and write. However, they can also detect a child’s difficulty in interacting with others who are too different from himself or in dealing with a different language from that spoken in the family. For the psychoanalyst, the key challenge of schooling is the child’s confrontation with new symbolic rules. These rules require that a kind of intimate knowledge is produced and can thus be seen as threatening to the knowledge the child already has, which is linked to his personal history. Teachers and psychoanalysts use different methods and tools, but they both work in the child’s interest, just like all other professionals who, alongside teachers, intervene to resolve the child’s learning difficulties: speech therapists, reeducators, movement therapists and so on.
Finally, as we all know, adolescents confront the adult world by questioning its authorities, because the emergence of genital sexuality forces each individual to find his own unique solutions, without being able to resort to a universal model. This phenomenon has been well documented by psychoanalysts who work with adolescents,, but also by practitioners from other theoretical fields,. In the difficult situations experienced by adolescents, the psychoanalyst represents an ethical refuge. For those around the young person – parents, doctors, teachers, educators, school nurses – he can provide a form of assurance, helping them maintain their symbolic position. The research carried out by psychoanalysts in this area has been shared and made public by learned societies such as the SEPEA in individual works,, or collective volumes, journals,, or via scientific events,.
3) Recommendations and innovative practices
Summary: Psychoanalysts are regularly closely involved in the clinical realities of childhood and adolescence; their work attests to the expectations addressed to them by children, adolescents and their parents, who wish for their unique questions, difficulties and struggles to be heard, one by one. Their work also concerns the social field, wherever the questions of caring for and the place of children are discussed, in terms of education or the facilities where they may be treated. Given this involvement and some of the preoccupations discussed previously, we can formulate a number of recommendations to fight against over-diagnosis and over-prescription. Their implementation can lead to the adoption of measures in favour of the free choice of treatment and guaranteeing the plurality of training programmes and research.
Over-diagnosis and false predictions
This phenomenon has been on the rise for already thirty years, mainly due to the increasingly more frequent use of the DSM. The diagnostic categories offered by the Diagnostic and Statistical Manual make it impossible to clearly distinguish between genuinely pathological behaviour and infantile and juvenile manifestations that are either reactive or linked to the ordinary crises of these periods (See above, Current situation).
The French Classification for Child and Adolescent Mental Disorders(CFTMEA), often endorsed by child psychiatrists, is more clinically and psychodynamically precise. Contrary to the DSM, it allows us to code environmental factors and includes a transcoding with the ICD (the International Classification of Diseases established by the WHO). Its use should be officially maintained and enable us to study epidemiological developments. In fact, it has previously been used in national surveys.
Contrary to the symptoms of somatic pathologies with quantifiable biological markers, the behavioural problems of a child cannot be reduced to a simple diagnosis.
When a diagnosis is established for regulatory reasons, it should be based on a precise clinical inquiry, formed by observing and listening to the child and his family, implemented by skilled professionals over a specific time period and taking into account all of the realities surrounding the child. Also, because the value of a diagnosis is in the therapeutic orientation it provides, it should from the outset be accompanied by setting up care for the child and support for his family.
Finally, in the case of young children, all early predictions should be avoided. This kind of discourse is in fact based on prejudice rather than knowledge. It can prove detrimental due to the risk of false positives and self-prediction, given that the child’s condition is constantly developing, but also and simultaneously because of the irreducible singularity of each child, which means that their destiny cannot be determined in advance.
The prescription and over-prescription of psychotropic drugs to children
In agreement with the recommendations of the WHO and the ANSM (Agence Nationale de Sécurité du Médicament, the French agency for the security of health products), psychoanalysts have contested the prescription of psychotropic medication to children. They believe that this practice ultimately always leads to over-prescription, as it is the case in the United States, where the figures are increasingly worrisome. Independently of its economic aspects and the costs it generates, drug prescription to children creates severe problems. First, as it is the case with most psychoactive substances, it leads to the usual misuse and trafficking. Second, there is insufficient data on their long-term side-effects and risk/benefit ratios, which dictates caution in their use at such a young age. Lastly, psychoanalysts know very well that while chemical substances do not serve to rectify a dysfunction or deficit (in the way insulin can work in diabetes), they do modify brain and psychic functioning and sometimes can lead to dependency. For these reasons, they should be reserved to extremely precise indications, only when all alternative therapeutic, educative, pedagogical and social measures have been implemented.
Free choice of suitable care for the child
Each child or adolescent and his family should be able to access, within a reasonable period of time, a local care facility with an interdisciplinary team, where they can meet with, should they so desire, a psychoanalytically-trained practitioner. Children and parents should be able to choose the therapies and care approaches concerning them and the latter should be adapted to each case. The signatories of this report therefore recommend that the training given to the future practitioners in medicine, psychology but also in other professional, paramedical, educational and pedagogical bodies maintains a high degree of psychoanalytic knowledge. For many decades, the humanistic approach of psychoanalysis has provided us with tools to think about psychic development and psycho-pathological manifestations, while also enabling us to understand the subtleties of psychotherapeutic relationships, including the dimension of transference.
Lastly, to help advance our knowledge in this highly complex field, it is important to guarantee the plurality of research, specifically in the vast field of clinical research.
D – Psychoanalysis and Culture
1) Historical background
Summary: For its founder, psychoanalysis was entwined with culture; this idea was present during all stages of its theoretical construction. While Freud wanted to study the human mind and its alienating productions, he was equally interested in its empowering creations. Philosophy was an inspiration for his studies alongside psychiatry. In his view, the inventiveness of the unconscious could be seen in dreams and delusions, but also in works of art and in the social organizations of “primitive peoples”. While psychoanalysis considers human culture as the price to pay for humans to overcome their animal condition, it is also attentive to the risks of regression this culture continuously has to face.
The relationships between psychoanalysis and culture can be seen from a number of standpoints. Let us start with definitions. According to Claude Lévi-Strauss, every society comprises two dimensions: 1) civilization(agriculture, industry, production, consumption, etc.) and 2) culture (art, spiritual practices, ethics, intellectual life, knowledge, etc.). However, what about our societies, characterised by the ambiguous status of science, which, inseparable from technology, is located at the intersection of these two spheres? In this sense, the present chapter on Psychoanalysis and Culture should be read alongside the chapter on Psychoanalysis and Scientific Criteria in this report.
Recognizing the fact of a continuous exchange between psychoanalysis and culture is therefore in line with one of the missions set up by its founder. Freud’s ambition to contribute to a genealogy of culture de facto liberates psychoanalysis from psychopathology as its sole register. In this sense, it implicitly draws on Erasmus’ Praise of Folly. The term psychoanalysis thus continues to designate a method of caring for psychic suffering, but like all individual psychology, it is also a social psychology.
The breath of Freud’s learning and his passion for other disciplines such as neurology, psychology and psychiatry are well-known facts. Particularly in psychiatry he had a considerable expertise and was well-read in the works of German psychiatrists such as Kraft-Ebbing, Kraepelin, Bleuler, Binswanger, etc., but also French psychiatry: Morel and, obviously, Charcot. During his medical studies in Vienna, he decided to complement his neurological and medical training by attending other courses: the lectures of the philosopher Franz Brentano, the cultural psychologist Wilhelm Wundt or, due to his interest in aphasia, the emerging science of linguistics. Freud’s tireless intellectual curiosity is in part responsible for the breath of the programme which he saw as necessary to the training of psychoanalysts, asking them to have a solid grasp of not just psychopathology, but also anthropology, religious studies and philology.
Attention to the socio-political context
It would be a mistake to see Freud’s insatiable cultural curiosity as simply a scholar’s search for amusement. In reality, he was always trying to keep up to date on the social and political realities of his time. Together with some of his disciples, he was passionate about applying psychoanalytic reading to certain aspects of modern culture, especially with regards to the organization of sexuality, both individually and universally. While the civilized sexual morality imposes certain sacrifices, the psychoanalyst should be able to say something about their “psychic cost”, based on the internal work of culture in each person’s psychic life. Freud’s thinking about culture was marked by certain disillusionments. After the First World War, he felt that all the sophistication and ideals of culture could easily be reduced to nothing. Arguing with Paul Valéry that today’s civilizations know themselves to be mortal, he wrote, in 1929: “The evolution of civilization may therefore be simply described as the struggle for life of the human species.”
Links to anthropology
What was the reaction to Freud’s theses? Already by the 1920s, the term “Oedipus complex” had become so ambiguous that it crystallized the misunderstandings between psychoanalysis and anthropology, specifically with respect to its potentially universal status. The mid-1920s thus saw a debate between the anthropologist Bronislaw Malinowski and the psychoanalyst Ernest Jones, alongside the field research carried out, around these same questions, by the psychoanalyst and anthropologist Géza Roheim. Travelling to remote traditional societies, Malinowski’s successors encountered communities whose patterns of child-rearing they did not understand. The family constellations they observed were quite different from the Western nuclear and conjugal family. Also, as Claude Levi-Strauss often stressed, the men and women in these societies found their symbolic bearings in myths often than the Oedipal myth. They of course knew that in order to have children, one needs progenitors, and that sexual difference is the condition of generational difference. However, not all of these societies were trying to celebrate, or even save, the pater familias and the conjugal family. In Africa, Marie-Cécile and Edmond Ortigues studied these questions in their well-known work, arguing that the child’s reference to his progenitors (mother and father) was independent of his family system, which could be either patrilineal or matrilineal.
For psychoanalysts, the question is therefore of situating unconscious thought – and thus the dimension of the drives – within the different forms of social relations and institutions. Addressing the fundamental question of the gift also means addressing the issues of exchange and sharing. In this sense, while anthropology and sociology have both changed the world by making it more intelligible, the contribution of psychoanalysis has been to explore the ways in which desire and prohibition are inscribed in family configurations that can be more distributed and flexible.
The invention of anthropology and the invention of psychoanalysis have therefore shared a large part of their journey with each other, without any apparent disagreements, misconceptions or misunderstandings. The influence of Levi-Strauss’ structuralism on Lacan’s thought is of course undisputable: the anthropologist’s conceptual tools enabled Lacan to make the analogy between “myth” of “complex”, leading to a rereading of Freud’s emblematic case histories.
The dialogue with cultural works
In Freud’s Totem and Taboo, anthropology appears as an interdisciplinary field which the propositions of psychoanalysis continue to develop even today. However, over the past century, psychoanalysis has also made its mark on other cultural fields. Freud’s interest in the Mediterranean region and Italian culture is well documented and he repeatedly tried to confront his discovery of unconscious life with certain works of the Renaissance. This was the case in his text on The Moses of Michelangelo, where he tried to include his analysis in the series of interpretations of the famous 500-year-old sculpture.
At the same time, Freud remained suspicious of the emerging field of cinema and the first film featuring the effects of a psychoanalytic treatment was in fact endorsed by two other psychoanalysts, Karl Abraham and Hans Sachs. However, psychoanalysis continued to inspire film-makers, including masters such as Alfred Hitchcock, John Huston, Samuel Fuller, etc.,as well as their 21-century successors: Benoit Jacquot, David Cronenberg, Arnaud Desplechin, Fanny Ardant, Manele Labidi, etc. Not to forget other authors and artists who have publicly spoken about the impact psychoanalytic work on their creativity.
In literature, Freud had a close relationship with a number of writers: Arthur Schnitzler, Romain Rolland, Thomas Mann, etc. Among these, Stefan Zweig dedicated a book to him and also delivered the eulogy at Freud’s funeral in 1939.
It is also crucial to take a more international perspective, because it was in part through culture and literature that psychoanalysis became established in a large number of countries. For example, a well-known Argentinean tango is called “Villa Freud”. In Brazil, the “anthropophagic movement” founded by the poet and playwright Oswald de Andrade and sharing certain ideas with surrealism, combined literature, psychoanalysis and anthropology to try and appropriate foreign cultures rather than reject them. In the Japanese literary circles, literature also enabled the spread of psychoanalysis through the figure of the leading Meiji writer Ogai Mori, who became interested in Freud’s theses on sexuality already in 1902. Starting from the 1920s, these works were also read and commented on by Chinese intellectuals, specifically the great writer Lu Xun. In Iran, psychoanalysis was practically smuggled into the country, following the 1934 publication of a novel by the politician and linguist Bozorg Alavi, inspired by Freud’s work.
Few among the European inter-war intellectual movements shied away from a dialogue with psychoanalysis, as attested to, for example, a special issue of the Belgian literary revue Le disque vert, published in 1924 andentirely dedicated to Freud.
Literature and psychoanalysis
Rather than draining the literary inspiration generated by the Freudian discovery of the unconscious, it seems that the two world wars of early 20thcentury had in fact only galvanized it. Again, this report can only provide a very incomplete picture; below, we have included a list of works, divided into three categories (essays, treatment narratives and novels), which were published, in no particular order, between 1970 and today and which show that the voice of literary creativity inspired by psychoanalytic thinking is indeed far from having been exhausted.
Bellemin-Noël J. (1978), Psychanalyse et littérature, PUF, 2002
Kristeva J. (1999-2003), Le génie au féminin. T.I Hannah Arendt, T. II Mélanie Klein, T. III Colette, Fayard
Tisseron S. (2000), Tintin chez le psychanalyste, Aubier Montaigne
Bayard P. (2004), Peut-on appliquer la littérature à la psychanalyse? Éditions de Minuit
Mc Dougall, J. (2008), L'artiste et le psychanalyste, PUF
André J. (2018), L'inconscient est politiquement incorrect, Stock
Weyergans F. (1973), Le pitre, Gallimard
Cardinal M. (1977), The Words to Say It, Van Vactor & Goodheart, 2013.
Perec G. (1986), Les lieux d’une ruse, in Penser Classer, Hachette
Rey P. (2009), Une saison chez Lacan, Points
De Montclos V. (2016), Leur patient préféré: 17 histoires extraordinaires de psychanalystes, Stock
Hachet P. (2016), La terreur en héritage. L’attaque de panique sur le divan, L’Harmattan
Betrisey JC (2018), Louis Kahn on the Psychoanalyst’s Couch, Collection du Divan
Novels and autofiction
Italo Svevo (1973), Zeno’s Conscience, Penguin Classics, 2002
Camon F. (1984), La maladie humaine, Gallimard, Folio
Chapsal M. (1992), Le retour du bonheur, Le livre de poche
Benacquista T. (2000), La boîte noire et autres nouvelles, Gallimard
Kaplan L. (2001), Le Psychanalyste, Gallimard 2001
Pontalis JB (2004), Le dormeur éveillé, Mercure de France
Orban C. (2005), Deux fois par semaines, Albin Michel
Yalom Irvin D. (2006), Mensonges sur le divan, Livre de Poche
Nathan T. (2006), Mon patient Sigmund Freud, Perrin
Henry Bauchau (2006), L’enfant bleu, Actes Sud (08/02/2006)
William Boyd W. (2012), Waiting for Sunrise, Bloomsbury, 2013
Philippe Sollers (2018), Centre, Gallimard
Lastly, on 4th June 2018, eighty years after Sigmund Freud stopped in Paris on his way into exile, his statue was unveiled at the Vienna University as a tribute to his life’s work.
2) Current situation
Summary: Over the past century, psychoanalysis and its concept of the unconscious have become major cultural and media references. While at times it was denounced as de facto hegemonic in certain areas, today psychoanalysis is experiencing a decline compared to new disciplines such as cognitive science. This new situation has forced psychoanalysts to invent new approaches to the contemporary social and cultural phenomena, trying to participate, in new and different ways, in the work of civilization.
The 20th century has sometimes been described as Freud’s century, showing the degree to which psychoanalysis had become ubiquitous throughout the Western civilization. Its popularity corresponded to the desire of its founder, who wished that society could benefit from its advances beyond the sphere of psychopathology. In 1919, Freud wrote: “[…] psycho-analysis can also claim to be of interest to others than psychiatrists, since it touches upon various other spheres of knowledge and reveals unexpected relations between them and the pathology of mental life.”
While Freud advocated the inclusion of psychoanalysis in the sphere of science, he also believed that its field was extraneous to its two neighbouring disciplines: medicine and psychology. He repeatedly tried to apply the analytic method to studying various works of art (Jensen’s Gradiva, Michelangelo’s Moses, etc.), making psychoanalysis a tool to think about cultural processes. After WWII, psychoanalysis played a significant role in the European culture and even globally. In 1970s France, its strong influence in education and the media was due to the large dissemination of Freud’s works translated into French, but also thanks to Françoise Dolto’s radio programme, which reached a wide audience.
In comparison, its influence has since declined: some argue that it has simply fallen out of fashion, others see it as anachronistic. In the field of mental health in particular, some believe this regression to be irreversible. However, what about other fields, such as those of the media and culture? To answer this question, let us look at a few examples.
From everyday language to mainstream media
The words and expressions derived from psychoanalysis are increasingly part of common parlance. This presence of the psychoanalytic vocabulary in everyday speech attests to a growing assimilation of psychoanalytic concepts. In French, some notions such as faire son deuil [“to go through a mourning”], passage à l'acte [committing an act], pulsion [drive], scène primitive [the primal scene] or indeed the Oedipus complex have become commonplace. Just like Molière’s Monsieur Jourdain and his prose, those who use these expressions are speaking “Freudian” without knowing it. This “omnipresence”, which helps produce an artificial familiarity with psychoanalysis, sometimes provokes irritation or even rejection, especially when accompanied by pseudo-psychanalytic explanations and interpretations that are in reality caricatural and stereotypical.
Moreover, psychoanalysts are increasingly more often solicited by the media, who seek their opinion on a wide range of subjects. Some of them, having become true media stars – contrary to Françoise Dolto, who always refused this role – are in great demand not so much for their expertise on the topic in question, but thanks to the audience they command. A number of psychoanalysts have thus agreed to share their views on political issues, social questions, current affairs or any other subject that has no real connection to their professional experience and simply represents the opinion of a citizen. The general population nonetheless believes that psychoanalysts have a particular knowledge about sexuality and the drives, but especially regarding unconscious thoughts as they manifest in everyday life. In the mind of the general public, this sometimes confers on psychoanalysts a special status, of a kind of omniscient super-expert, who can speak the truth about society and its cultural habits, both those of the elite and those of the people, and who is able to dispel prejudice and illusions.
Far from helping disseminate psychoanalysis or strengthen its cultural legitimacy, this situation instead reveals the divisions among psychoanalysts regarding the issues of our time, especially when it comes to the changing mores. For example, these divisions were patent in the debate on gay marriage, where some analysts were in favour of the new legislation while others expressed reservations or even downright resistance. This recent example makes it clear that when it comes to these types of questions, in which the intimate and the social are closely intertwined, no one is qualified to speak publicly in the name of psychoanalysis.
Sometimes used by the media as a kind of “court jester”, the public psychoanalyst is therefore given the privilege of treating, in his own way, any given subject. However, he is then immediately removed when it comes to discussing serious scientific questions. In this way, psychoanalysis runs the risk of being reduced to “opinion” or “belief”, unable to prove its legitimacy and, in some cases, its efficacy.
A definite place in culture
Though we can only offer a very incomplete view, a paradigmatic example will give us an idea of the changing position of psychoanalysis in our culture. During most of 20th century, an entire area of philosophy, the so-called “social critique”, was allied with psychoanalysis. Max Horkheimer and Theodore Adorno, the key figures of social critique and members of the Frankfurt School, integrated psychoanalysis in their philosophical work. They used some of Freud’s concepts and publicly recognized their utility in deciphering the crises of European civilization, especially its wars and genocides.
Within this school of philosophy, the influence of psychoanalysis then declined and even disappeared with the work of Jürgen Habermas. At the same time, the influence of notions distant from analysis, such as the “ethics of care”, became more prominent. This ethics “condemns social ills such as sexism, homophobia, racism and so on, caused by the patriarchal paradigm of our democracies, as well as the forms of suffering inherent to the individual’s vulnerability and his exposure (physical and psychological) to the injuries of those he is close to.” Twenty years later, we see a return to psychoanalysis, with Axel Honneth, the current Director of the Institute for Social Research, who writes: “The concern for the injuries and suffering they engender situates social critique in the field of pathology and engages it in thinking about the constitutive dimensions of the individual’s ‘integrity’ (both physical and psychological) and the social conditions of its preservation. What is important here is that the aetiology of social suffering calls for, in different ways, psychoanalysis…”
Digital media and the dissemination of psychoanalysis: training and teaching
Since the beginning of 21st century, we have seen the emergence of new media which constantly expands the possibilities of communication and exchange, but also improves our access to knowledge. They have helped bring about a new era, which psychoanalysis has seized on and benefited from. Millions of articles, documents, books and archives concerning psychoanalysis from its very beginnings are now publicly accessible via different websites. The information listed in these directories is added to the lectures and study days that are also regularly uploaded on specialized platforms or shared on social media. Long reserved to only the initiated, this information is now shared freely, giving psychoanalysis real public visibility. At the same time, a number of works presenting the sum of psychoanalytic knowledge available in France and abroad have also been published.
Overall, this situation has brought considerable benefits to the teaching of psychoanalysis and the training of analysts. It gives them access to a complex body of knowledge developed over more than a hundred years, while keeping account of the debates marking this evolution.
Just like experts in other domains of knowledge, psychoanalysts have taken part in the effort to provide reliable psychoanalytic references, including on Wikipedia. Finally, the teaching of psychoanalysis also makes use of webinars, allowing certain psychoanalysts to create communities of practice. These communities are platforms allowing individuals sharing an interest or a passion to speak together and interact in order to learn from each other. The psychoanalytic website oedipe.org is one example among many.
Effects on psychoanalytic practice
Contrary to psychotherapists who, under the impetus of the International Society for Mental Health Online (ISMHO) have started to offer online therapy and supervision (for example using Skype), psychoanalysts continue to reflect on these possible modifications to the analytic setting. The latter traditionally relies on the patient’s and practitioner’s physical presence, as well as on the agreed time of the session. The use of new media raises new ethical questions, which must be discussed: confidentiality, the role of the image, data encryption, etc. Within the International Psychoanalytic Association, this debate started already in the 2000s.
The recent transmission of psychoanalysis in countries such as China or Japan de facto requires modifications to the setting in which it is practiced.
To conclude, while some believe that the unregulated use of Skype can undermine psychoanalytic practice in terms of ethics, others argue that throughout the history of psychoanalysis, the different changes to the classical setting of the treatment have enriched both theory and practice: the development of psychoanalysis with children and adolescents, psychoanalytic psychodrama, psychoanalysis and family therapies, etc.
3) Recommendations and innovative practices
Summary: In the broad cultural field, the credit of psychoanalysis has been fluctuating. The current period is a crucial turning point, forcing psychoanalysts in all their diversity to become better at explaining the significance of the Freudian discovery. According to Freud himself, civilization is “the whole sum of the achievements and the regulations which distinguish our lives from those of our animal ancestors and which serve two purposes—namely to protect men against nature and to adjust their mutual relations.”
From its beginnings, Freud’s ideas have been entwined with the work of civilization and still have a place in it, without for that matter neglecting the advances made by cognitive science, neuroscience and artificial intelligence. Faced with the explosion of digital technologies and their applications, new media and the rise of ‘post-truth’, psychoanalysts have a role to play, specifically in objecting to the excesses of scientism and naturalism when the latter become reductive, populistic and authoritarian. Maintaining the place of psychoanalysis in our culture thus requires us to remain vigilant in a number of areas.
The role of sexuality: The drives between Eros and Thanatos
No culture, regardless of how liberal it may be, can escape the civilizing principle discovered by Freud: drive renunciation. In this sense, the drives are untameable and are constantly looking for the satisfaction denied to them. While in the form of the social Eros they have a role to play in the construction of the social link, their egocentric and sometimes destructive orientation simultaneously generates hatred and disconnection. In Civilization and its Discontents, a text he continued to revise, Freud contrasts Eros (the life drive or love drive) with Thanatos (the destructive or death drive); their constant interaction is one of the main sources of the structural ‘discontents’ within culture. While culture on the one hand displaces and sublimates the sexual drives, it also has to constantly repress them, hence its inevitable and unliveable “malaise”. As a key moment of entering the social field and culture, schooling is the privileged space in which the fate of these sexual drives is played out. The outcome depends on our interaction with others and on the traumas we have experienced, i.e. our environment.
In spaces of education, the work of psychoanalysts should continue in order to help prevent a climate of excessive repression, so that education does not become the equivalent of animal training. They should oppose doctrines that naturalise and biologize the child’s behavioural symptoms. Yet looking for the meaning of these problematic behaviours inevitably runs contrary to the efforts of parents, the school and society to simply “manage” them as best as possible. Psychoanalysis sees these behaviours as “neurotic” symptoms, which express a conflict between the demands of the drive and the limits imposed by education. If they are seen and interpreted in this light, the child can find an acceptable compromise. The neurosis described by psychoanalysis thus also has an anthropological dimension, making it the symptom of culture as such.
However, the disappearance of the term “neurosis” from the American classification of mental disorders has led some authors to believe that the feelings of guilt have disappeared as well. These authors have argued that the psychic suffering of post-modern men and women no longer stems from their guilt, but from their narcissism. Rather than anchored in the guilt linked to the impossibility of settling one’s symbolic debt or accepting the limits imposed on one’s enjoyment, the sources of the depression of today’s subjects, who are exempt from guilt, supposedly originate in their inability to meet the ever-more demanding social expectations. Their wounded narcissism thus requires constant reparation, leading to, among others, the different addictive behaviours aimed at procuring immediate gratification.
By replacing guilt with narcissism as the source of the symptoms addressed to psychiatry, this sociological conception nevertheless obscures unconscious conflict. In addition, it effaces the quasi-infinite variety of the forms the singular drama of drive renunciation can take.
The murder of the father and Oedipus: Two foundational myths
Freud’s work reminds those who believe in the quasi-unshakeable solidity of human culture that, following Darwin’s ideas, its origins in fact lie in the primal horde. Subjects to the rule of an all-powerful “father” who alone possessed all women, the “sons” rebelled and killed the father, ingesting his flesh during a “totemic” meal. The fantasies and symptoms expressed today follow up on this mythical origin of the first civilized human groups: murder and incest. These two archaic behaviours, which have since been transformed, in one way or another, into taboos, have nevertheless remained part of all human societies. The psychoanalytic model of human psychic functioning associates this first myth to the myth of Oedipus, which too evokes, in a different way, its criminal origins, including its incestuous component. When he adopted this idea, initially articulated by the psychologist Wilhelm Wundt, Freud considered that the primitive system of taboos represented the most ancient unwritten code of humanity, dating back to a period prior to religion.
In the legal context of today, the works of more than a few experts have been inspired by these psychoanalytic ideas (see the chapter on Psychoanalysis and Scientific Criteria).
While the law reminds us in actual fact that the work of civilization is never finished, psychoanalysis helps us stay vigilant on at least two different levels. One, it is universally opposed to ideologies that are normative and seek to subject all human beings to the criteria of a “scientifically-approved” normality. Two, on the clinical level, the psychoanalyst works on a case-by-case basis, trying to make intelligible, with each patient, the archaic material that emerges in their behaviours and fantasies. Defending the hypothesis of the Freudian unconscious, psychoanalysts are encouraging their fellow human beings to hear, in their own speech, an echo of the part of themselves unbeknownst to them, which may suddenly surge in their words or actions. Contrary to unconscious cognition, the role of which has been demonstrated in neuroscientific and cognitive psychology experiments, the Freudian unconscious appears unexpectedly, both on the public scene (the parapraxes and bungled actions of media actors, politicians, presenters, journalists, etc.) and on the private and intimate scene (in dreams, forgetting, unexpected and irrepressible emotions, etc.).
The place of language
From the beginning, the psychoanalytic experience has shown that language is more than a simple communication tool. During his stay at the Salpêtrière in 1886, Freud understood that words had an effect on the body’s reality. He observed that his hysterical patients reacted as if anatomy did not exist; in other words, their symptoms (paralyses, organ dysfunctions and so on) followed no organic logic. Today, we hear this idea in the most commonplace comment regarding medically unexplained symptoms: “It’s all in his head.” Whilethese symptoms appeared independent of anatomical reality, Freud discovered that by listening to these patients, he was able to reveal the symptom’s unconscious meaning. Previously seen as a “simulation”, this new reality enabled him to glimpse, beyond anatomical and functional reality, a different order of reality present in medicine: the psychic reality. The role of language in the human psycho-corporeal development was later theorized by Jacques Lacan, who articulated it, in 1956, as: “The unconscious is structured like a language.” His formula was later adopted by Françoise Dolto in her book Tout est langage(“All is language”). Psychoanalytic practice, which is now expanding into the East, tends to confirm this understanding.
After the “decade of the brain”, which was ruled by the interest in brain anatomy and saw the creation of large-scale research projects such as the 2013 Human Brain Projector Brain Activity Map Project, it is crucial that psychoanalysts continue their work founded on the multiform, complex and irreplaceable role of language. Deepening the imbalance in favour of brain matter alone would also increase the risk of gradually turning away from the specificities of the human psyche.
However, social relations and the technologies of governance underpinning them necessarily depend on language and interlocution. The theory and practice of psychoanalysis teach us that language represents an essential component of the symbolic dimension founding the social pact.
The stunning discoveries in the area of brain functioning sadly neglect one crucial fact: although the brain is indeed a necessary condition for psychic life, it is not a sufficient one. For psychic life to emerge and be able to express itself in a human being, we also need something else, namely the interaction with others.
This in part explains the misunderstandings regarding the question of autism. On the one hand, psychoanalysts have long ignored the realities of the autistic brain, instead emphasizing the psychic reality, which they had been dealing with for many decades. On the other hand, the neuroscientists, who understandably wished to take advantage of their dazzling discoveries in the area of brain functioning, ignored these relationship professionals, who stubbornly kept working with autists and their families, with varying degrees of success. Today at last, a kind of equilibrium is beginning to take shape in terms of responding to the issues related to autism.
In general, the democratic principles in public health dictate that users must be able to freely choose among the methods used to relieve psychic suffering. Respecting the law, psychoanalysts offer their skills to people experiencing mental distress, without a priori rejecting other methods of treatment. However, they also expect their own method -- supported by a coherent body of knowledge on the human psychic reality, its functioning, complex development and specific logic -- to be respected. They believe to be best placed to implement and develop this method, because prior to offering it to others, they have themselves personally experienced its validity and efficacy. While self-experimentation in medicine is courageous, it is certainly not original. Some have died as a result of it, such as John Crandon, who wanted to prove the contagious nature of yellow fever in 1939, while others have highlighted the importance of subjecting oneself to what one intends to administer to one’s patients.
In psychiatry, we know that Esquirol (1772-1840) underwent some of the treatments intended for his patients (cold showers, diets, etc.) and in more recent times, the psychiatrist Cornélia Qarti volunteered to receive the first injection of chlorpromazine in 1951.
The difference between these medical self-experiments and psychoanalysis has to do with the fact that the latter only functions in a relational context. The person who decides to undergo analysis does not simply experience its effects passively, but instead gradually accedes to certain truths, about himself and his personal history, which he had been unaware of. While this framework offers a guarantee of sincerity, the truths it helps reveal are always singular. Paradoxically, the risk taken by psychoanalysts is to structure their work around these truths, which ultimately resemble ephemeral and partial beliefs. However, the regular conferences and national or international colloquia during which their theoretical advances, training techniques and practical modifications can be discussed and confronted with each other remain the best way of continuously preventing excesses and abuses.
In the era of fake news, in our so-called ‘post-truth’ culture, psychoanalysis continues to refer to the notion of truth, which is inseparable from exercising critical thought. Still, some of the criticisms aimed at it at the present time appear to have more to do with stereotypes and prejudice rather than rigorous argumentation. Saying that the Freudian unconscious is a 19th-century belief made obsolete by modern science, means ignoring the contributions that psychoanalysts have made to the study of various modern phenomena, such as serial murders, same-sex parenthood, the social withdrawal of youth (hikikomori)or Islamist radicalization.
From every point of view, psychoanalysts have gained the right of including their clinical works not just in the framework of scholarly scientific research, but in the entire French cultural landscape,,,.
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Universités : Angers ; Aix-Marseille : Université de Provence ;Lille ; Lyon2 ; Montpellier ; Poitiers ; Rennes ; Rouen ; Strasbourg ; Toulouse2. Universités Parisiennes : UP5, UP7, UP8, UP10-Nanterre, UP13-Villetaneuse.
Haut Conseil de l’évaluation de la recherche et de l’enseignement supérieur. Il s’agit d’une AAI (Autorité administrative indépendante), chargée de l’évaluation de l’enseignement supérieur et de la recherche publique.
Séminaire inter-universitaire européen de recherche en psychopathologie et psychanalyse
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