Débat

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The so-called advanced societies are experiencing a period of value disruptions. Thanks to some extraordinary technical advances in communication and information and globalization, we can now experience in real time, individually on the Internet and collectively through television medias, the political events and natural disasters that affect our daily lives and force us to rethink our status a citizens in relation to the limits of our nationality. And this happens while the development of education and the globalization of markets, and their effects on the freedom of the citizens (birth control and euthanasia are two examples that spring to mind), allow everyone, everywhere, to access information that were previously kept out of the reach of the masses.

Moreover, global warming creates more and more human and social problems that no nation will be able to solve on its own, in a splendid isolation that would allow the rich countries to ignore the poor. Whether we want it or not, we are faced with a global geopolitical and human problematics whose purview and processes, yet unknown and even unsuspected by certain people, place us in a context that, not long ago, ordinary psychiatry would have referred to as hallucination and psychotic delusion. We are gradually losing the illusions of a common perception of what is acceptable and of a collective awareness of values. And everyday clinical practice based on listening to the subject in psychosis ridicules this kind of reference to delusion.

The time when psychiatry could be conceived as the means used by a society to exercise control over socially harmful or at best unproductive madness is over. We have imperceptibly slipped into another problematics. As our societies, which are increasingly dominated by the commercialization of health, tried to control and treat, in individuals alone, the consequences of a society choice, the consensus which supported that choice crumbled. It is also undermined by a constant review of its legal framework, under the influence of political and economical struggles.

Democratic states define the orientations and the administrative and financial frameworks of the health services that will be offered to those of their citizens who suffer from severe mental illness. Admittedly, they are now introducing the concept of recovery as a desirable objective of the care provided, but it is in relation to the orientations and frameworks just mentioned that they ultimately evaluate these services. The evaluation of mental health services based on the objectives sought by the users is not yet a rule officially promoted. The managers, the institutions, the research scientists and the clinicians, we are constantly told, are under no obligation to get results, but to use means, except when it comes to psychoanalysis, of course.

The networks of university research scientists in mental health that are financially supported by the State or by private foundations, study and promote care strategies, and practices and evaluation methods with either sociological and anthropological problematics, or biological and behavioral problematics. At the same time, companies offer ready-to-use products by exercising a decisive influence on the administration of the care and the financing of the system. The State, the research scientists, the companies, these three main agents of the network have very different objectives, even when they get together to alleviate the consequences of the tensions resulting from their conflicting interests. But they all aim to provide care defined by factual data concerning some strategic groups of patients. They necessarily agree on care that are invariably the same for any group of patients with similar characteristics.

Patient groups and associations of parents, relatives and friends of persons suffering from serious mental illness, organizations and community groups and the foundations that support them, will become increasingly prominent as agents in the public health networks. As citizens, they are applicants in relation to the State, when it comes to the control and the management of public services, but they are in the position of clients in relation to the research scientists and the companies. They expect to recruit the clinicians as allies in their quest for health and a better life for the persons they love. As for the clinicians, they may find themselves in the situation of hostages, bound to programs, methods, rules and administrative, associative and financial constraints that weaken or flatly block any practice that doesn’t reduce the patient to an object to fix or an organism to treat.

Despite that framework in which the care are provided to the patients without the providers knowing the real causes of their problems, the living environment and the health conditions of those who suffer from serious and persistent mental problems have remarkably improved. Whatever critics and legitimate dissatisfactions can be associated with these services, there is no doubt that they bring hope to these people, and to their families and relations, compared to what offered to them fifteen years ago. For many, however, this progress remains superficial compared to what the discourse of neurosciences and genetics allow to expect.

In that general context and given the constraints imposed by the integration into a public network, a profound renewal of psychoanalytical practices and clinic must today urgently reconsider the issue of the treatment of psychoses as an offer made to the psychotic subject. That offer must take into account the main achievements of today's psychiatry by rethinking them within a psychoanalytical problematics in which the psychoanalytical treatment is the axis of the therapy.

Such an endeavor is not without risks, since it obvious as any critical observer of the present and recent history of mental health services will notice, that a serious problem runs through these services. They are increasingly conceived and organized to respond much more to the general requirements of public health networks that to the requirements of a clinical practice based on individual cases. The medicine that is taking shape before our eyes is geared at care designed for groups of similar cases and to the research that promotes it, individual cases remaining the exception that are useful only to clarify the problems and obstacles encountered by such a clinical practice. With its proposition of a clinical practice aimed at individual cases, psychoanalysis finds itself at odds with the practices of public health networks that are more influenced by statistics, costs, and budgetary and administrative consequences, as well as by media and political effects. The objectives, the rules and the evaluation criteria of the practices specific to the public network, centered on such a clinical practice for groups and case-mixes, take precedence over the results of a clinical practice dealing with individual cases.

Yet, twenty years of clinical practice show that a personalized approach of psychoses responds remarkably well to the expectations of the persons suffering from such problems and their entourage, with a different effectiveness and different results. The war on psychoanalysis, seen as a useless or even dangerous approach, nevertheless goes on. However, in Quebec, it tends to go nowhere, as it holds as its main argument that psychoanalysis is not based on proven data. Such an argument may however apply to a problematics of research and care practices centered on a medicine for client groups. The more personalized approaches, such as the psychoanalytical treatment of psychoses, can now pass the test of verifiable results that establish the relevancy of practices that are proven and whose specific conditions and logic must be studied.

Beyond the results of an official evaluation ordered by the State, which the detractors of psychoanalysis were hoping to use to exclude it from the clinical field, the psychoanalytical treatment of psychoses can report clinical practices that efficiently helps psychotic patients re-enter social life as citizens. It can account for the possibility to evaluate the results of more personalized approaches of psychoses that re-open or keep open the debate on various problematics of care and treatment, or even on the difference between care and treatment in the field of psychoses in particular.

The dialogue between neurosciences and biological psychiatry, on one hand, and psychoanalysis on the other, can re-center the debate and stimulate research on both sides. It remains that, for the ordinary patients and their entourage, the issue tends more and more to be boil down to this: What can psychotics hope for today? What can they hope for, between competent care aimed at remediating their neurobiochemical or genetic deficiencies while improving their life in society, and a treatment based on an offer made to the subject to allow him to become aware of his implication in what is happening to him and, with the help of a multidisciplinary team, to take on the ethical responsibility for his health?

A conference devoted to this issue will allow for an in-depth reflection and an open discussion on what supports and opposes these two paths. The preoccupation for what brings them closer can then only be better emphasized. Both have the same clients whose expectations and requirements should guide our practice, just like they question the positions taken by the public authorities. We hope that the contribution of each side to the questions addressed to its practice will turn this meeting into an important event for psychotics and the people who help them in their quest.