The principal author’s one-year stay at the Stanford university child psychiatry clinic allows French and American practitioners to compare their clinical practice of the treatment of Anorexia Nervosa in adolescents.
The two countries’ differences are less founded in theoretical references than in the cultural context and the system for financing medical care.
Hospitalisation and outpatient care indications and conditions are compared. The discussion shows the advantages and disadvantages of the two practices. The interest of the therapeutic separation, which no longer exists in California, is commented upon.
Archives de catégorie : ENG – Psychothérapie III – 2006 T.24 n°2
Maurice Corcos : the weight contract in hospital treatment of mental anorexia : separation, reappropriation, subjectivation
The weight contract in hospital treatment of mental anorexia, first inscribes in the heads of the patient and her family the disavowal of concern for somatic reality and its outcome, at risk of grave complications. Then it quickly becomes clear that the question is not the fantasized one of « force feeding » through a medical technique that will make her fat, but that of the process of becoming a woman, hampered by the girl who actively and willingly aborts her adolescent process. This symbolic effect of the contract has effects on the body and thought processes of the patient, allowing for revision of identifications. The constraint experienced in the therapeutic act is always much less than the violence of primitive relations of the subject of the ego with its archaic superego and aims to ease the interior constraints at the origin of food restriction and weight loss. « External » persecution opposes an internal dictator … the conflict is displaced onto the relation with the treatment (which figures the conflicts with the parents) and allows for the emergence of new possibilities of representation. The conflict is human again and for a while disavowal, splitting and projection will occur, as defenses, before the encounter within the conflict becomes possible, an encounter which protects the patient’s narcissism (she is not humiliated by asking for help, the bond having been imposed upon her). This encounter allows for an exploration of the patient’s deep desires, and her degree of resistance in disavowal or the veneer of conformism. It is this dialectic of desire and resistance which allows a diagnosis to be made in economic terms since, fundamentally, it is desire that builds alienation. The contract is a technical artifice, which provokes a separation situation deeply feared by both the patient and her family, and which reveals the complexity (nature, intensity, ambivalence) of parent-child bonds and the fantasies they have generated. It allows us to study the central issue of separation: procrastination about the weight at the moment of separation and the weight at the moment of leaving the hospital, fetishism of a certain weight, reactivation of separation issues when the patient is discharged from the institution. Adopting the language of the symptom and placing it within the framework of the weight contract, the psychiatrist can then deploy his offer of living treatment within the psychotherapeutic space.
André Alsteens : interpretation in the encounter with an adolescent
This article points out the place of verbal communication, interpretation and the use of the transference in the encounter with adolescents, emphasising the subtle and continuously variable dosage which has to be established between these three parameters if one wishes to promote a living and fruitful dialogue.
Guy Scharmann : hand games
Using three different references (a small survey, a book by G. Haddad, and two clinical vignettes), the author tries to raise some questions about the handshakes exchanged at psychoanalytical and psychotherapeutic sessions; a way of investigating, through this aspect of the setting, the place of the body in the treatment, and its eventual « putting into the session ».
Daniel Oppenheim : the adolescents undergoing a treatment for a cancer and the feeling of confinement
The impression of being locked up in the world of illness, hospitals and medicine is part of what adolescents experience while undergoing treatment for cancer. This impression is exacerbated when they receive high-dose chemotherapy and a stem cell transplant in protective isolation. Confinement combines with and exasperates all aspects of their experience of cancer, especially the perturbation of their relationship with their body (which becomes strange or unfamiliar) and with others (withdrawal, flight, excessive demands, anger), of their sense of identity, difficulties in formulating and expressing their ideas, fear of thinking. Their parents are also upset. In order to help these adolescents live through this phase of their treatment and this confinement without being destabilized and, subsequently, to rid themselves of its psychical repercussions, psychoanalysts need to be sufficiently aware of the reality of this experience so that they can work on the elements of which it is composed and not on a rough definition of what it is and what phantasms it evokes. We describe first the elements involved in these treatments then the landmarks which can guide the psychoanalyst in these particularly difficult and complex situations.
France Audiffred : « Can we go where we never go ? »
In institutional clinical treatment, blind adolescents are often heard to complain of not being seen. Emerging from invisibility presupposes facing the Other’s gaze, which is essential to specular validation and to the question of lack and of loss induced by sensorial deprivation.
Abdelhadi Elfakir : the tale between dream and speech : a way of articulating the subject with the group
The subject of the unconscious and the collective maintain consubstantial relations. They are like inside and outside for one another. The passage from to the other is accomplished as if over a Mœbius strip where inside and outside are indistinguishable. If the subject of the unconscious is the effect of the laws of language, this is not without being colored by collective productions and their institutional set-ups which, through a certain collective arrangement of speech and utterances, dig canals and confer upon it specific modes of expression. The tale and the dream, as they may refer to each other and unfold in a singular speech, aim to be the privileged means of grasping this articulation. An illustration of this is given here using a clinical research encounter, in the context of oral tradition, with an eleven year-old girl, recounting the marks of a fate for signs of a dreamed destiny.
Laurence Chekroun : there’s a time for everything
Thoughts come to me in session, which I talk about right away, or else store up for days, weeks, or even years. Far from being set aside, they are all around us during the session and frame us. I illustrate what I am saying with the psychotherapeutical trajectory of an adolescent boy, first treated between the ages of thirteen and fifteen years, who then came back to see me at the age of eighteen. There comes a time when it is essential to express those thoughts that have never been mentioned. During the second part of his psychotherapy, when he is having trouble coming regularly to his sessions, I will put them into words.
Serge Hefez : tie me up. dangerous liaisons of the couple and the family
The author investigates the modifications of personality structure linked to specific changes in society and culture, mainly modifications of family life and modes of socialization.
The family therapist must take into account the social dimension of narcissism. It is necessary to work on marital and familial bonds in relation to the imperatives of freedom and the weakness of external constraints in limiting them.
Jacques Hochmann : trend effects and psychotherapies
Psychical reality is outmoded. Hypnosis or learning theory-inspired therapies are now considered to be the only ones that work. Psychoanalysis should study their functioning in order to gain an understanding of their way of operating.