François sauvagnat: recent challenges of psychoanalytic therapies

Whoever is interested in psychotherapic practices will not fail to hear this fre-quent advice coming from authors claiming to give credit to „evidence-basedtechniques”: psychoanalysis is not „in” any more; new techniques have showngreater efficacy at lower cost. As we will see, not only have these assumptionproven to be flawed, but also, this kind of viewpoint seems tightly related tothe prevalence of recent tendencies in the apprehension of psychopathology.
One can wonder whether theses tendencies represent a significant progress.
Until recently, psychopathology kept trying to be an adequate and a consis- tent domain (that is, to give an accurate description of the current knowledgeabout symptoms and a fair discussion of the possible aetiologies). But in thelast decades, more lateral approaches have prevailed. A common trait of theseapproaches is that both consistency and adequacy have been discarded: thesubtleties of inner pathological experiences are left aside to the profit of one-sided techniques.
Until recently, most authors accepted to discuss such fundamental theoret- ical frameworks as the classification models, the sydenhamian model, theprocess model, the continuist and discontinuist models of psychopathology;the syndromist model and the theory of clinical types; the models opposing adeep structure and phenomena; organicism, sociogenesis and psychogenesis;this is no longer the case. Psychiatric symptoms were classified in function oftheir severity, and their complexity inspired to clinicians a feeling of humility.
Brilliant psychopathological systems, like Kraepelin’s theory, had given littleresults; Karl Jaspers had proclaimed that it was too presumptuous, only to findthat his own principles would prove insufficient to account for disorders likeparanoia. Psychoanalysis has from the start accompanied the slow progress ofpsychopathology; almost all the neuroses and personality disorders have beendefined by this discipline, which refused to proclaim the existence of a distinct „normality”, showed humility concerning its results, did not hesitate to discussfailures (including „negative therapeutic reactions”), and encouraged practi-tioners to envisage their own insufficiencies before charging the patients’resistances. Even if their results were quite comparable to those of organicphysicians, analysts generally showed modesty and refrained from pretendingto promote general happiness, conscious that this was too intimate and com-plex a matter to be measured by usual standards, especially in terms of thecapacity of the patient to accept happiness. Even if frequent references weremade to the sciences (and all of them), psychoanalytic technique was consid-ered to be more an art than a science, a view which in no way seemed deroga-tory. Seven recent paradigms have attempted to put and end to this, and arecurrently considered as „mainstream”. In the following lines, we shall examinethem and discuss their pretensions to account better for the clinician’s task.
1. Psychological symptoms are currently presented as industrial opportunities.
What is required is the social identification of a mental suffering or disorder,
and the announcement that a certain substance or technique is liable to pro-
duce a quasi miraculous healing. It is well-known that some pharmaceutical
drugs have benefited from enthusiastic presentations in the US press, even if
the research concerning them showed little or no difference from the effect of
placebos (as in the case of SSRI antidepressants) (Kirsch) or preoccupying
addictive effects (as in the case of attention-deficit disorders „enhancers”) – in
France some „quick methods” for treating traumatic symptoms have also ben-
efited from a cheerful press promotion in spite of the modesty of their results.
The high frequency of these journalistic promotions does not shock anybody
anymore. The only limit drawn to these enterprises is the eventuality of scan-
dals – usually, the death of patients. The peculiarities of these practices have
been carefully documented by authors like David Healy or Peter Breggin, but
curiously enough, the protests raised have mostly been identified with „parti-
san” point of views. In fact, this approach of symptoms is currently seen as
inevitable; complementarily, patients are often referred to as consumers, even
if a wide majority of them (especially the persons with the most severe
pathologies (Narrow WE & al. 2000) refuse to be considered as such. The fact
that this approach is tolerated for economical reasons should not mean that it
is scientifically or even practically justified.
2. Psychological symptoms are considered in terms of risks: this view, initiated
by health insurances specialists, has immensely percolated into public preoc-
cupations. From this point of view, psychopathological symptoms have no kind
of specificity, and they are simply envisaged alongside cardiovascular diseases,
drug or alcohol consumption, cancer, etc. The only questions asked are how
much is this bound to cost, who will take responsibility for the expenses, how
François Sauvagnat: Recent challenges of psychoanalytic therapies it is predictable, and consequently more or less preventable. Although theseissues are quite fascinating, the prevalent view is that the „risk” cannot be any-thing else than a factor of economical benefit or loss. Consequently, the ideahas prevailed that ready-made comparisons can be done: clinicians wereencouraged to promote the techniques promising the fastest and cheapestrecovery. A huge proportion of the research on psychotherapies focused on„evidence-based” studies, centered on virtual therapeutic situations assimilat-ed to drug prescriptions, discarding the more demanding investigation on real-istic processes in actual psychotherapies. In the meanwhile, „cognitive tech-niques” drawing on simplified psychoanalytic models (Kandel 1998) had beenpromoted; they were initially classified together with „psychodynamic thera-pies”, but finally their promoters chose to merge them with behavioral tech-niques; these techniques included procedures in which patients were persuad-ed to evaluate their own sufferings according to ready-made scales and toadhere to the values advocated by their „trainers”. In the flow of publicationsproduced along these lines, manualized cognitive-behaviour therapies werepresented as doing comparatively better than psychodynamically orientedtreatments, until researchers tried to know whether the alleged results wereenduring. Several „fast techniques” have thus been shown to be of modest effi-cacy. In an extensive 2005 investigation on long-term outcomes of patient withanxiety and psychotic disorders benefiting from BCT, Durham et al (NationalHealth Service, UK) found that the alleged favourable results did not persistin the long run, that the ameliorations were at best modest in anxious casesand practically impalpable in psychotic cases, and that the number of relapseshad been heavily underestimated. An increase in the number of sessionsbrought no overall improvement. On the other hand, research on the outcomeof long-term treatments of similar patients with psychodynamic therapiesshowed favourable results (Leuzinger-Bohleber).
3. Within the framework of the sociological school of Chicago (Erving
Goffman), mental symptoms came to be understood in terms of social stigma,
characteristic of an extreme class of disadvantaged individuals; stigmatization
was understood to be a means of maintaining a sort of „military reserve”, in
the terms of Friedrich Engels. This concept has undergone various modifica-
tions as it was inserted in the domain of cognitive psychosociology (Corrigan)
and medical sociology (Link & Phelan). Whatever the merits of theses elabo-
rations may be at the service of ailing individuals and disadvantaged groups, it
is quite clear that their connection with psychopathology is somewhat loose, as
they content themselves with the evaluation of social acceptability or rejection,
i.e. the empowerment of stigmatized individuals, usually avoiding to evaluate
the respective momentum of social versus purely psychopathological factors,
let alone the possible interference between both. The immense popularity of
„self-diagnosis” on the basis of so-called „internet information”, invitingsurfers to self-label what they may be suffering of, has changed many „self-helpgroups” into lobbies craving for social recognition.
Individuals are publicly invited to join survivors associations, most of the time at the expense of personal privacy and sound psychopathological science.
Many of these lobbies have been instrumentalized by commercial and indus-trial interests, happy to see that the drugs or techniques they propose can thusfind a ready list of consumers. Several controversial labels, such as „multiplepersonalities” (Sauvagnat 2001), Attention Deficit with hyperactivity, etc.,have thus been operationalized by powerful industrial interests (Breggin), anda growing number of „survivors” nowadays confront clinicians with unwar-ranted but highly structured demands.
4. Diagnosis has become a perilous exercise at a time when the categories of
the DSM are publicly voted for or against by assemblies of the American
Psychiatric Association influenced by various lobbies (Vedantam), instead of
being carefully documented by scrupulous research. As a result, the signifi-
cance of categories that took decades to be carefully elaborated has been lost
sight of and new categories have been hailed inconsiderately. Neuroses have
been declared inconsistent and sliced into „personality disorders” and „disor-
ders”; some categories, like „pervasive development disorders”, have pervad-
ed into an uncontrollable spectrum, to such a point that it is not unusual to see,
in the U.S., judges decide who shall or shall not receive the corresponding
diagnosis and financial support. Childhood bipolar disorders have become a
frequent diagnosis in the same geographical regions, whereas this category is
seen as aberrant in other continents, where the prescription of thymo-regula-
tors before teen age is conceived as a dangerous practice. And most of all, the
issue of co-morbidity has been totally underestimated. It is not rare to see most
of the DSM categories present a co-morbidity of more than 50%, a figure that
can well exceed 80% in the case of ADHD.
5. An important proportion of the historical research in the domain of medical
sociology has repetitively followed the „paradigm” of „institutional motives”.
Ignoring the fact that clinicians will usually try to heal their patients, and
inspired by R Kuhn’s triumphant theories, theses researchers have decided
that the use of clinical categories or therapeutic techniques is mainly a ques-
tion of power. Individual motives were thus considered as being of little rele-
vance, as compared to the idea that competition between „scientific groups”
and downright ambition will always structure the personal implication of a
man, no matter what his scientific engagements may be. As a result the histo-
ry of clinical categories, for instance monomania, has been drained of their
practical significance; the human conflicts have been seen solely as conflicts of
François Sauvagnat: Recent challenges of psychoanalytic therapies power, to such an extent that the succession of concepts has become an incon-sistent series, „full of noise and fury”. It doesn’t seem to occur to some of thesehistorians that the original definition of monomania, i.e. partial madness,could have some sort of practical and clinical meaning. The history of clinicalresearch and practices is now seen as an evolutionist domain, and the survivalof the fittest is conceived as its only prevailing law. History, at the turn of the19th century, had become a critical domain, in the sense of the Neo-kantians;a century later, it seems to have become the mere justification of industrialstrategies. Amazingly few clinicians (for instance Berrios) dare to counterthese unwarranted pretensions.
6. A curious alternative has recently appeared on the scene: as the personal
motives of clinicians and researchers were no longer understandable, could
they not simply be understood as evil? A curious sect has recently come forth,
pompously dubbing themselves „Freud scholars”, who pretended to track
down the real motives of the creator of psychoanalysis: Freud simply wanted
his patients to get worse. Animated by tenebrous instincts, craving to win social
recognition, devoid of minimal human sensitivity, Freud is portrayed as having
lied on his results and on the biographies of his patients. The complexity of
cases, the complexity of symptoms, could thus be reduced and simplified into
an all-pervading doubt. Hasn’t he expressed doubts on his own capacity as a
therapist? Hasn’t he declared that he was „like Moses”? Freud’s doubts could
then be reduced to a horrible secret, that of a wicked man. Nowhere have the
„resistances against psychoanalysis” expressed themselves so crudely as in the
recent conspirationist prose of the „Freud bashers”. But the very fact that most
of them come from a precise cultural domain can be taken as a precious indi-
cation of the value of their criticism. In a famous book, a Canadian historian
of psychiatry, Edward Shorter, remarked that psychoanalysis has never really
been welcome in the USA, and that in spite of what has been frequently stat-
ed, it has never been deeply accepted outside „Jewish and Feminist circles”.
The gross exaggerations that are so frequent in the rhetoric of the Freud-bash-
ers can rightfully be considered as a trademark of a certain form of ethnocen-
trism, especially in some North-American protestant circles. Freud’s insistence
on the role of sexual drives, the way he valued confession, his attacks on reli-
gions, his views on ethics, frontally contradicted this puritan and predestina-
tionist tradition. The very fact that other cultural domains avoided to criticise
his theories too frontally, and even, in the case of West-European liberal
Christianity (French Catholic and Reformed and recent German Katholische
and Evangelische Kirche), significant portions have repetitively tried to recon-
cile their doctrines with Freudianism, can also be seen as a confirmation of this
7. Biological research has dramatically developed in the last decades, opening
new fields of research but giving little unambiguous results. In a domain that
traditionally overlapped psychological and biological research, psychosomatic
symptomatology, it has become usual to consider disorders in terms of neuro-
psycho-endocrino-immunology, as the main regulation systems of the human
body have proven to be deeply connected with each other. But such a complex
approach probably sounded discouraging to researchers eager to touch a wide
public, and the reductionist approaches, popularized by the mass-media (the
„discoveries” of dozens of „candidate genes” have been trumpeted to be the
„cause” of mental diseases in the last two decades, with hardly more positive
result than ideological discourses encouraging political deciders to pour more
funds into biological research) have failed to demonstrate clear-cut causalities
in most cases. A notable quantity of biological research has therefore adopted
a „lateral” strategy, in their attempts to establish a „forced relationship”
between a psychopathological phenomenon and a single biological mechanism.
In this kind of reductionist approach, researchers content themselves with
establishing a link between the activation or inactivation of a certain cerebral
region and a known pathology to declare that they have found the biological
cause of this disorder, which should eliminate alternative explanations. This
„result” is then „proclaimed” by an opportunistic press campaign. Recently, a
researcher has claimed to have discovered that autistic individual showed a
characteristic activation of the temporal region, discarding at least four already
available alternative explanations, and even considering that her „results”
should allow political deciders to fund „ sensory training programmes” of autis-
tic children, and refuse such fundings to psychotherapies aiming at establishing
intersubjective relationships and better emotional regulation. In this case, this
researcher clearly considered that she had a right to „prescribe” certain tech-
niques, even if their evaluations had already proven that they were flawed.
We can easily divide these paradigms in two kinds: some are tainted with rela-tivism, others can rightfully be called reductionist. Reductionism has allowedorganic medicine to boast significant results, for instance in the domain of neu-rology and oncology; but to what extent can it be applied to psychopathology?As long as the neurosciences do not yield more uncontroversial outcome inthis latter domain, there is no sound reason to consider that the more realistic„bio-psycho-social” model (Engel), and its psychosomatic correlate, neuro-psycho-socio-immunology, or the Lacanian models integrating the highly indi-vidualistic issue of jouissance (intimate, sexual body-structuration) and thepsychopathological effects of social discourses should be discarded. Psychicmatters in general resists to reductionism, especially in the psychotherapeuticdomains. Rigid prescriptive psychotherapeutic programmes (“trainings”)achieve little success and are frontally confronted to negative therapeutic reac- François Sauvagnat: Recent challenges of psychoanalytic therapies tions, as Durham’s groundbreaking research has shown. Nevertheless, theycontinue to be hailed and prescribed for perfectly cultural reasons. Forinstance, in the case of adolescent psychopathology, North-American practi-tioners are encouraged to prescribe drugs (generally prohibited in the UK),and to apply behaviour-cognitive programmes of desensitization, self-esteemimprovement and aggressivity control, although these have proven to be lesseffective than antidepressants, which in their turn have shown to produce lessresults than…placebo! The fact that the more versatile psychodynamic psy-chotherapies have proven to produce better effects (Fonagy & Target 1998) iscuriously not taken in consideration, and it would be difficult not to admit thatcultural motives do not play here a predominent role.
Such cultural factors are even more striking in the case of Attention Deficit with Hyperactivity. In the US, practitioners have been encouraged to prescribeRitalin (a substance close to cocaine) to children presenting with this sort ofdisorders, and even to shift to mood regulators in case of failure, the practiceof cognitive-behavioural therapies being presented as optional. In the UKpractitioners are discouraged to give attention-regulating drugs to the childrenand encouraged to send the parents to behavioural „parenting programmes”…(Sauvagnat 2006) To these two current mottoes, relativism and reductionism, we would like to oppose two others: complexity and socio-cultural determination, two traitsconstantly underscored by European psychoanalysis. A psychopathologicaltheory that does not acknowledge a sufficient degree of complexity in thehuman psyche simply misses its goals, and does not prove anything else thanthe narrowness of its own socio-cultural determinations. The stress currentlyput on „control” in „manualized” psychotherapeutic practices has shown itslimits. The focalization on „social risks” has tended to silence the fact that clin-ical terminology is nowadays socially determined and prescribed, as F Erõs hasdemonstrated about holocaust trauma, the labelling decisions may have verylittle to do with the intensity of the ailments (Erõs 2006). The same restrictionshave also tried to silence the fact that behind and alleged symptomatology, ahuge diversity of subjective fantasies and unconscious positions can be found.
As J Lacan (inspired by the founder of the theory of probabilities, BlaisePascal) has shown in his seminar D’un Autre à l’autre, a subject should be seenas a gambler, as a pawn in the game of the Other, as a stake within his family,as a party in an ordeal trial. This is what unconscious fantasies are about.
There is absolutely no reason to consider that patients should be any simplerthan poker players.
If the use of simplified methods has always been an admissible practice, one should not oversimplify human subjectivity; conscionable clinicians should notpretend that simplifying methods will simplify humans. As Kandel has shown,practically all simplified psychotherapies have been inspired by psychoanalysis – at least for ethically acceptable psychotherapies – in an attempt to respondto social demands. But symptoms are also a protest against social demands.
There is no sound reason why conscionable practitioners should not turn topsychoanalytic strategies that have not been manualized.
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