Cantin, L. (2009) ‘An Effective Treatment of Psychosis with Psychoanalysis in Québec
City, since 1982’, Annual Review of Critical Psychology, 7, pp. 286-319
http://www.discourseunit.com/arcp/7.htm
AN
EFFECTIVE
TREATMENT
OF
PSYCHOSIS
PSYCHOANALYSIS IN QUÉBEC CITY, SINCE 19821
WITH
Lucie Cantin
“ Humanity begins with the voice that introduces a universe that
transcends both the space of perception and the management of the
physical and social environment. Psychosis is the ineffaceable witness of
this intellectual dimension, which reminds us that the mind is the uniquely
human capacity to produce mere representations, to which nothing
corresponds in perceptible reality, and that overdetermines every
dimension of perceptual reality as it is socially defined.”
Willy Apollon, 2009
“Psychosis is a language and if one succeeds… if I succeeded in decoding
this language, then I would succeed in no longer using it.”
Patient’s discourse
In Québec city, since 1982, there has been a Center for the psychoanalytic
treatment of the psychoses. More than a hundred patients receive a
comprehensive and long-term treatment there which includes intensive
treatment of the crisis, thereby assuring them of an alternative to
hospitalization. Ninety-six percent of the clientele is composed of persons
suffering from schizophrenia and other psychoses, the majority of whom
present, upon their arrival, an extensive psychiatric past of multiple
hospitalizations and diverse therapeutic attempts.
Lodged in a superb old three-story Victorian house, and located in the
very heart of an active neighborhood of the city, the Center is communally
designated by its civic address, “The 388”. It is a name which has, with time,
become a symbol in the healthcare circles of the Province of Québec, and which
has also become vital for the psychotics as the signifier of a reliable landmark
where they are able to speak and to address psychoanalysis with the object of
their most intense preoccupations.
Since its creation, we have wanted to offer a treatment to the psychotic by
proposing an analytic work to him wherein he is engaged, guided by the
GIFRIC (Group Interdisciplinaire Freudien de Recherche et d’Intervention Clinique) is a private
non-profit organization. It gathers a group of over forty professionals and academics around
research and projects mainly in the fields of psychoanalysis, mental health, the family, and
socio-culture. Among these projects is the Center for the psychoanalytic treatment of psychotic
adults, “the 388”, conceived and created in 1982 by Gifric, which has developed an innovative
psychoanalytic treatment. The “388” is financed by the state, and its services are therefore
public.
For more extensive information, the reader may consult Gifric’s website at
www.gifric.com
1
286
Cantin, L. (2009) ‘An Effective Treatment of Psychosis with Psychoanalysis in Québec
City, since 1982’, Annual Review of Critical Psychology, 7, pp. 286-319
http://www.discourseunit.com/arcp/7.htm
psychoanalyst, in reconsidering his entire psychic life. The objectives of this
treatment are the profound reorganization of the mental universe, the
reappropriation of speech and subjectivity, the disappearance of the psychotic
symptomology, the resolution of the stakes governing the triggering of the
crises, the restoration of an autonomy in personal and social functioning, and
the return to an active life of civic participation (work, studies, volunteer work,
artistic work, familial responsibilities). The analytic treatment — which is at the
heart of the work undertaken by the psychotic at the 388—is at the center of a
treatment’s structure, which receives, frames, and treats the effects of this work
through a set of services, all of which are determined by the logic of the
analytic experience and the ethics it commands. These services include: a
personalized psychiatric follow up, articulated and adapted to the evolutionary
stages of the analytic treatment; the in-house accompaniment and treatment of
the crisis—the Center has seven beds available for this end; daily clinical
supervision and support by clinical intervenants2 who are trained to ensure a
“long-term psychoanalytic follow-up”; art workshops run by artists who come
in order to practice their art with the patients of the Center; and finally, an
activities program that aims at the restoration of the social link and the
preparation for a return to an active life.
“The parents have seen their children come out of isolation and affirm their
personalities as they progressively move through the phases of social
rehabilitation. The parents particularly appreciate the fact that the
treatment enables the capacities of each to be optimized to reach a
recovery level they no longer thought attainable.”
Evaluators’ report, 2002:10
The psychoanalytic treatment, here, is a specific experience with the objective
of attaining precise results, translating into concrete transformations in the
psychotics’ lives. It is not conceived of as a work of the comprehension or
interpretation of psychic life. Psychoanalysis for us is, before anything else,
the implementation of an ethics. It aims at the production of a knowledge (a
savoir derived from the experience) of the Unconscious that must be actualized
in the subject’s acts and changes of position, which have the manifest
consequences of the disappearance of the psychotic symptomology and the
reorganization of the whole of life. These are the effects in which true clinical
results are recognized. For those who are truly engaged in this analytic work,
we note that the rate of success is greater than sixty per cent.
We choose to keep the French term “intervenants” (clinical intervenant) to designate the
professionals trained by Gifric to ensure the long-term psychoanalytic follow-up, on a daily,
weekly, or monthly basis depending upon the evolution and stages of the treatment. The
“clinical intervenants” have different backgrounds (psychology, anthropology, nursing,
philosophy, etc.) before the psychoanalytic training given by Gifric.
2
287
Cantin, L. (2009) ‘An Effective Treatment of Psychosis with Psychoanalysis in Québec
City, since 1982’, Annual Review of Critical Psychology, 7, pp. 286-319
http://www.discourseunit.com/arcp/7.htm
Some remarks are necessary here concerning the Center’s clientele. The
literature tells us that after a first psychotic episode, “20 to 25% of patients see
a marked improvement. It could be a matter of a spontaneous remission, of a
sole hospitalization followed by a return to prior functioning, or a social
adaptation that is judged to be acceptable even without treatment. The
majority (50 to 60%) of patients also have a satisfactory development, thanks to
pharmacological treatment. Only 5-15% of affected individuals have a more
reserved prognosis, despite treatment” (Villeneuve, 2008: 52, 54). Other
researchers, who are less optimistic but without a doubt more realistic, note
that even with an appropriate anti-psychotic medication, about 50% of patients
will experience a relapse in the 5 years that follow a schizophrenic episode
(Remington, 1994), or even still that 25% of those suffering from schizophrenia
display a resistance to treatment (Curry, 1985). In 1982, at the time of the
Center’s creation, the target clientele was those with psychoses in their initial
stages of development. Yet, it so happens that we admit, and have always
admitted, a clientele situated much more in the percentage of psychotics who
are resistant to traditional psychiatric and hospital treatment. The majority of
patients have had an average of four to five hospitalizations before their arrival
at the 388 (some of them, up to fifteen hospitalizations), and they all have an
evolution that is resistant to the various types of treatment that have been
attempted thus far. The Center, in fact, admits a clientele that is usually
treated in the specialized and overspecialized services of psychiatric hospitals.
The obtained rate of success is therefore all the more important to emphasize.
“The partners involved (other hospitals, psychiatrists in the health system,
community organizations, crisis centres…) all report that the clientele
referred to and observed at the 388 have serious and persistent disorders
which many psychiatrists would hesitate to treat outside the formal
hospital setting.” Evaluators’ report, 2002:12
Furthermore, these facts concerning the clientele treated at the Center
constitute, in and of themselves, a response to the reservations that are
normally raised about schizophrenics’ “capacity” to enter into analytic work.
The question of the “selection” of patients, which certain people believed to be
inevitable in a Center for psychoanalytic treatment, finds itself de facto
dispelled by the clientele admitted to the 388, which turns out to be the same
as that admitted by healthcare professionals in a hospital setting. In the same
way, the obtained clinical results put forth a challenge to the reservations
published in the literature and psychiatric practice guidelines about the
pertinence of psychoanalytic treatment with psychotics—a treatment qualified
as ineffective, indeed, “inappropriate”. Our twenty-seven years of practice with
psychotics have not only largely proven the contrary, but they have been the
occasion for us, as psychoanalysts, to advance the technique and theory of the
analytic clinic in a way that puts it at the service of a clientele for whom it had
288
Cantin, L. (2009) ‘An Effective Treatment of Psychosis with Psychoanalysis in Québec
City, since 1982’, Annual Review of Critical Psychology, 7, pp. 286-319
http://www.discourseunit.com/arcp/7.htm
been neither thought through nor conceived.
which deserves particular attention.
We will return to this aspect,
“The approach consisting in a personal commitment on the part of the patient
as a requisite to admission to the 388 in no way operates to prevaricate the
selection of the clientele, which objectively involves serious cases. The
partners noted improvements they were unable to obtain themselves in their
earlier dealings with the same patients.” Evaluators’ report, 2002 :12
A final remark about the Center’s clientele and the obtained results is
necessary here. “The 338,” by its very existence and its now well-known and
recognized clinical results, constitutes an offer of psychoanalytic treatment
addressed to the psychotics. Our criterion of admissibility, then, is defined by
the psychotic’s response to this offer. Not that the patients of the 388 present
themselves with a skillfully formulated and clearly articulated demand, but
they will at least have taken the personal step of making a phone call in order
to ask to be admitted. The psychoanalysts who will receive them in an initial
interview are charged with mobilizing within them the decision to implicate
themselves in a treatment that cannot be initiated without their active
participation. The clinical results essentially depend upon the psychotic’s
response to the offer we make him to be engaged, along with us, in an in-depth
treatment whose aim is to realize the objectives he wants to attain and the
changes he says he wants to effectuate in his life. Thus, it is not a matter of
affirming that psychoanalytic treatment responds to the needs of all psychotic
and schizophrenic clientele. Some patients still refuse to be implicated in an
in-depth treatment, choosing instead to be taken into the charge of a team of
caregivers who are responsible for their well-being. This is an ethical choice
that concerns each individual, and one that we must respect. But, our
experience is that if we manage to mobilize the person suffering from
schizophrenia—whatever his level of disorganization may be—and if he decides
to implicate himself in the analytic work, then he either manages to overcome
the psychotic symptomology and recover complete autonomy and civic
participation, or he progresses and develops well beyond what the psychiatric
literature and so-called “evidence based data” would predict.
In the age of cognitive-behavioral therapies…
In view of the clear acknowledgement of the insufficiency of
psychopharmacology in the treatment of the psychoses, and in the face of biomedical research of all sorts which seek to establish the biological and genetic
causes of psychotic symptomology, a current of “psychological” research has
developed which explores the affected mental faculties of the person suffering
from psychosis with the means offered by neuroscience. In this view then, it is
a matter of understanding and explaining psychotic symptomology through the
various dysfunctions, deficits, biases, and cognitive disorders which lead to the
289
Cantin, L. (2009) ‘An Effective Treatment of Psychosis with Psychoanalysis in Québec
City, since 1982’, Annual Review of Critical Psychology, 7, pp. 286-319
http://www.discourseunit.com/arcp/7.htm
inappropriate behaviors and “errors” of interpretation that are responsible for
the psychotic symptoms.
The cognitive-behavioral therapies established on these researches have
now overrun the field of psychosis and have become, according to the practice
guidelines, the “evidence based practices” and the most appropriate
“psychotherapies” in the treatment of schizophrenia. One can only be delighted
that certain therapists recognize here an improvement upon the “behavioral
interventions of the 80s” which “did not take into account the individual’s
subjective experience, either his goals or his aspirations.” These are the same
researchers who will once again take up the idea that “psychoanalysis is
inadvisable with psychotics” (Lecomte et all., 2008:63) and will emphasize that
“it is only recently, with the adaptation of cognitive-behavioral therapy for
psychosis, that a psychological intervention has taken an interest in the beliefs
and perceptions of the people suffering from psychosis in order to help them
attain their goals” (idem: 63).
The term psychotherapy that is employed here presupposes a certain
conception of the psyche. The psyche here is effectively understood as a
collection of faculties which are locatable in the functioning of the brain, itself
understood as an organ, and which allow the individual to have a normal,
correct, and appropriate adaptation to his environment. Such a conception of
the psyche implies a certain number of presuppositions, including, among
others, effacing the subject of the Unconscious by reducing the human to the
status of an individual who is supposed to behave in the same manner as all
other individuals of the same species, since all are endowed with the same
organism and the same faculties. And yet, researchers in neurosciences, each
within their own field, never fail to emphasize the complexity of the psychic
disorders encountered in the clinic, and the limits of the statements at which
they arrive.
“Given the great heterogeneity of the neuropsychological
symptoms associated with schizophrenia, even considering its sub-groups, it
seems more appropriate to examine the specific profile of each patient”
(Gendron et all., 2008: 42). And later, on the subject of the cognitive deficits
encountered in schizophrenia, they add: “Nevertheless, none of these cognitive
deficits characterize schizophrenia such as it is defined today, nor do they
systematically affect all patients, with the result that we must, for the time
being, confine ourselves to correlations” (idem: 45). Some researchers of
functional neuroimaging in the physiology of the positive symptoms of
schizophrenia go further by admitting that “the pathogenesis of schizophrenia
remains little understood” and also emphasize “the phenomenological
heterogeneity of schizophrenia,” which would explain the difficulty of
understanding it. “The severity of the clinical and cognitive disorders,” they
say, “can vary from one patient to another, with neither pathognomic
phenotype nor specific biological markers” (Pelletier et al., 2008: 25).
These different warnings, however, did not impede the establishment of a
certain number of consensuses upon which the cognitive-behavioral therapies
offered to psychotics are based. “Several studies,” the researchers tell us,
290
Cantin, L. (2009) ‘An Effective Treatment of Psychosis with Psychoanalysis in Québec
City, since 1982’, Annual Review of Critical Psychology, 7, pp. 286-319
http://www.discourseunit.com/arcp/7.htm
“have attempted to more specifically identify the neural correlates of auditory
verbal hallucinations (AVH) by using a variety of neuroimaging techniques,”
and arrive at the conclusion that “AVH are the consequence of a dysfunction of
the treatment of internal discourses and thoughts” (idem: 27-28).
Neuropsychological theories, they clarify, “stipulate that patients suffering from
AVH perceived their own discourses and thoughts (words generated in an
internal fashion) in the form of a voice coming from an external source” (idem:
27). As for the delusion, “the most recent studies in cognitive neuropsychiatry
suggest that these delusional ideas are just as much the result of deficits as of
the emotional and cognitive biases that affect the reasoning, attention, and
memories of people who are susceptible to being delusional” (idem: 27, 29). By
affirming in this way that the hallucination is “the consequence of a
dysfunction of the treatment of internal discourses and thoughts” or that it has
been empirically demonstrated that “the voices heard by certain people
suffering from psychosis can be linked to an erroneous attribution of their
internal discourse to an external source,” (Lecomte et all, 2008: 64) we will
have learned nothing that the psychoanalyst has not already known for a long
time. The hallucination is only described here in its phenomenology. Freud,
and Lacan after him, will have gone further by remarking that “what is
foreclosed in the symbolic reappears in the real,” noting that that which was
censored and has never been represented returns, likewise, “from the outside”.
The definition of the delusion, centered around “the deficits and/or cognitive
biases affecting reasoning,” certainly raises question of the norm and logic in
relation to which an idea can seem to be an error of reasoning. In fact, one
cannot avoid defining this norm, which in this case is certainly constituted by
the social norm, common sense such as it is interpreted by the researchers, as
well as the shared belief that determines an inside and an outside in relation to
what is meaningful and founds the social link in a given culture at a given
time. It suffices to look from one culture to another, from one civilization to
another, from one religion to another, in order to grasp the arbitrary dimension
of the foundations of Meaning and “normality”.
But even in admitting the definitions of the hallucination and the
delusion that derive from neuropsychological theories, we will not have said
anything about the singularity of the delusional and hallucinatory contents,
nor their organization in a fantasmatic logic which is proper to each psychotic.
At the very most, we will have admitted that “the erroneous attribution of
internal discourse to an external source” is “influenced by the person’s beliefs,
particularly in what concerns the omniscience or omnipotence of the voices”
(idem: 64). Indeed, the absence of a distinction between the individual and the
subject in the neuropsychological conception of the psyche is decisive.
Psychoanalysis is interested in the subject, which we could summarily define
as that which, in the Unconscious, speaks, decides, and acts unbeknownst to
the individual and his consciousness. Psychoanalysis works in that mental
space which is not manageable by the individual’s link to the environment.
291
Cantin, L. (2009) ‘An Effective Treatment of Psychosis with Psychoanalysis in Québec
City, since 1982’, Annual Review of Critical Psychology, 7, pp. 286-319
http://www.discourseunit.com/arcp/7.htm
Productions of the mind, the imaginary, drives, and fantasies create a unique
psychic universe where the subject’s acts originate and are based in reason.
Furthermore, and above all, it is important for us to emphasize the
specific terrain upon which cognitive-behavioral therapy operates. All of these
definitions—of the hallucination, the delusion, and indeed even of thought,
defined as “words generated in an internal fashion”—upon which the
development of cognitivist therapies rely also determine a very specific
conception of the objectives of treatment. The fact that the hallucination and
delusion are reduced to errors of attribution or interpretation effectively defines
the aim of the treatment, where it will essentially be a matter of correcting the
psychotic’s thought with respect to an established norm, a proper perception,
an interpretation that is appropriate to reality, and the appropriate links
between perceptions, emotions, and behaviors. CBT (cognitive-behavioral
therapy), we are reminded, “permits the modification of thoughts and beliefs
which are unadapted to reality by teaching patients about the link that exist
between perceptions, beliefs, and the emotional as well as behavioral responses
to which they are connected” (idem: 64). “The therapist tries to normalize the
unusual experiences, such as the voices, either through the bias of
psychoeducation or by offering examples of particular situations” (idem: 67).
The “case formulation approach” in CBT will consist in presenting the
formulation of the problematic to the patient “through a figure including the
elements linked to the person’s predispositions, beliefs, emotional or behavioral
reactions, and symptoms…”, with “this formulation then being explained to the
patient by integrating the basic concepts of CBT…”. A “new explanation of the
lived experiences through the utilization of the stress-vulnerability model” is
then presented, and “the formulation becomes the motor of the therapy” (idem:
67).
These therapies, which are established, it seems, on “evidence based
data” therefore have very specific aims and suppose a particular conception of
psychotic symptoms and their treatment. They are, without a doubt, very
useful and effective within the frame of their own objectives. Moreover, the
relatively brief training they require from clinicians certainly plays a part in the
interest they arouse.
“In psychoanalysis, one of the things that you do is to try to investigate all
your memories and dreams – what is the color, what is the scenario, what
repeats itself; and when one discovers what repeats itself, one realizes
that it is certainly not reality that makes something repeat, it is our
perception, it is our experience, it is not reality!” Patient’s discourse
Psychoanalysis, at least the one we are proposing, is not located on the same
terrain and does not have the same aims. It makes another offer of treatment
to the psychotic. Not only does it rely upon an entirely different conception of
psychosis and its symptoms, but it works in the mental space where the
hallucination and delusion can only be apprehended in the internal and
292
Cantin, L. (2009) ‘An Effective Treatment of Psychosis with Psychoanalysis in Québec
City, since 1982’, Annual Review of Critical Psychology, 7, pp. 286-319
http://www.discourseunit.com/arcp/7.htm
singular logic which articulates them and determines the subjective position as
well as the set of symptoms and behaviors that hinder the psychotic’s
connection to the social link. It is not that the psychotic would be suffering
from some cognitive deficit affecting his reasoning, his attention, and his
memory, but rather that these are monopolized by a completely different
internal work which cuts him off from others and makes him disinterested in
“reality”. Psychoanalysis also abandons the objectives of correcting thought,
rectifying behavior, and readapting to the environment in order to dwell on the
object of the passion that mobilizes the psychotic and causes these “biases” of
thought, these “deficits of attention,” and his retreat from the objects of
common interest which create and maintain the social link.
...A new psychoanalytic treatment
With “the 388,” for the first time, a group of psychoanalysts created a
treatment Center for which they had thought through all of the services, the
organization, the structure, and the style of management, by beginning from a
psychoanalytic conception of psychosis and its treatment. Aside from the
novelty of the psychoanalytic treatment offered, the originality and success of
the 388 lie, on the one hand, in the inscription of each of its services within a
treatment’s structure created by the effects, stakes, and exigencies of the
analytic work, and on the other hand, in a management structure whose
connection with the clinic is guaranteed by the active presence and authority of
psychoanalysts in strategic decision-making roles. Thus, by being heavily
implicated in maintaining the conditions that have proven to be essential for
obtaining clinical results, the psychoanalysts frame the set of clinical practices
and guarantee their connection to psychoanalytic ethics. We will examine each
of the following three axes: the analytic treatment such as it is rethought and
redeveloped in relation to psychosis, a treatment’s structure produced by the
effects of psychoanalysis, and a management linked to psychoanalytic ethics.
The analytic treatment at the heart of the comprehensive
treatment offered to the psychotic
A clinic of the subject of the Unconscious
“Here at the 388, one is truly the subject of the treatment”
“Here you are at the heart of the work. You have the tools but it is up to
you to do the work. That’s the difference. And central to this, is the
analytic treatment.”
293
Cantin, L. (2009) ‘An Effective Treatment of Psychosis with Psychoanalysis in Québec
City, since 1982’, Annual Review of Critical Psychology, 7, pp. 286-319
http://www.discourseunit.com/arcp/7.htm
“To treat psychosis without looking into the unconscious, to ignore the
manifestations of the unconscious along with the voices and such things,
is not to go to the source of the problem.” Patients’ discourses
The psychotic experience and its spontaneous work
From the beginning, we have taken the approach of apprehending psychosis
neither through a theoretical conception that explains its cause, nor through
its phenomenology such as it appears to the observer, but rather by taking our
bearings mainly from the experience that the psychotic tells us about in his
discourse when we listen to him. As Freud chose to listen to what hysteric
women, who were supposedly suffering from nervous degeneration, had to say
and thereby discovered a mental universe from which he was able to think
through the logic of a psychic treatment, so too did we set out to do in the
consideration of psychosis. This assumes, of course, a particular position of
the clinician who is capable of addressing the psychotic about his intimate
experience and of triggering within him an assumption of speech that the
clinician must then be able listen to and support in its development.
Access to the psychotic’s experience and mental universe has made it
clear that the psychotic is captivated by a psychic work which always has an
objective, an object more or less elaborated in a discourse.
In this
“spontaneous work,” as Willy Apollon has called it, the psychotic is attempting
to organize a collection of lived experiences, hallucinatory phenomena, and
mental representations which are entirely original and disconnected from the
environment, all within a system that elaborates their logic and gives them a
signification.
The delusion is thus constructed as an explanatory and
justificatory theory that establishes the reason for the hallucination through
the construction of a private myth that, on the one hand, specifies a defect in
humanity which is responsible for the chaos whose effects he experiences in
his body, and on the other hand, outlines “the” solution that he himself is
“called” to carry out. This passionate object to which he has devoted himself,
this “enterprise,” captivates his entire mind and determines his interests and
disinterests, his attitudes and behaviors.
Likewise, the failure of this
spontaneous work provokes periods of emotional collapse that he works
through by reconstructing and reorganizing his “system” as best he can. The
delusional explanation, the delusion properly speaking, is clearly not always
structured nor even elaborated in a discourse. But there is always a work at
the very heart of the psychotic experience, whether it is the reconstruction of
the external world (a new order of things, a new language, a new humanity), or
a sacrificial position wherein the being—bearer of a Fault that is responsible for
the disorder afflicting humanity—is withdrawn, condemned, and disappears,
carrying with it the source of the defect. In this case, where the delusion is not
accessible because it is not elaborated in a discourse, the object of the
psychotic enterprise will be revealed in the analytic treatment, bit by bit, by
identifying the logic that organizes the content of the hallucinations, the
294
Cantin, L. (2009) ‘An Effective Treatment of Psychosis with Psychoanalysis in Québec
City, since 1982’, Annual Review of Critical Psychology, 7, pp. 286-319
http://www.discourseunit.com/arcp/7.htm
unfolding of acting out, the content of physical symptoms, and the staging of
the crisis. Thus, one must always be concerned with the question of knowing
what, precisely, is the object of the work that animates the psychotic and
occupies his whole mind.
The constraint imposed by transference on the censored work of the
“Thing”
“There is a logic in mental illness.”
“Unconscious processes made me act in a particular way; and that I had
no consciousness of these processes.”
“I think that the unconscious was acting without my knowing it. I had hit
bottom and I thought that I must explore this unconscious and stare it in
the face in order to see where these manifestations come from and all this
was happening to me.” Patients’ discourses
The calling into question of the delusion by the knowledge of the
Unconscious
The subjective experience that the psychotic tells us about gives us access to
his mental universe and a singular logic which seems to structure it, but which
escapes us at first. In fact, the explanation that the delusion is ceaselessly
elaborating bears witness to a unique psychic experience which finds neither
its mode of expression nor its solution. The censored work of a nonrepresentable, never represented, “Thing” is working in the being and
captivating the body. This is what is borne witness to by the hallucination and
psychotic phenomena that the delusion and enterprise fail to treat. It is this
censored work of the Thing, of Das ding as Freud would say, that the
psychoanalyst targets and that he will act, through transference, to constrain
to finding a form of expression and a way to be represented.
This constraint imposed on the work of the Thing by transference begins
with the offer of an address made by the psychoanalyst to the psychotic’s
Unconscious. In his encounter with the psychoanalyst, the psychotic is
exposed to that which has been put into place in the analyst’s own personal
analysis, which determines his position, guides his listening, and triggers an
assumption of speech in the psychotic about his intimate experience and the
organization of his mental universe.
The psychotic is solicited and
interpellated in his experience of psychosis. He is called to find the words to
say what he has never truly formulated and developed in speech addressed to
another. Upon the occasion of this assumption of speech, and the development
of it that the analyst insists upon, the psychotic enters into a new experience.
He encounters a constraint internal to language—the resistance of the words
295
Cantin, L. (2009) ‘An Effective Treatment of Psychosis with Psychoanalysis in Québec
City, since 1982’, Annual Review of Critical Psychology, 7, pp. 286-319
http://www.discourseunit.com/arcp/7.htm
that do not manage to account, in a satisfying way, for what he has
constructed in his imaginary. The analyst, through his position and his desire
to access something other than the delusional explanation, upholds this
internal constraint of language by maintaining the exigency of elaborating
thought in speech, while still questioning the logic of the delusional
explanation at its weak points. The points of failure in the delusional
explanation and the jumps in logic—which are camouflaged by affirmations
and certainties derived from the “revelations” coming from the voices—
effectively underline the failure of the interpretation produced by the delusion,
which is unable to manage the hallucination and give it a meaning that can
prevent it from surging forth.
The analyst does not interpret, nor does he propose any kind of
“understanding” of the psychotic phenomena in opposition to the interpretation
produced by the delusion. It is not, effectively, a matter of countering the
delusion or of attempting to stabilize or soften it, but rather of constraining the
psychotic to produce a knowledge other than that of the delusion, which would
then account for the fundamental experiences at the origin of his psychosis. It
is the psychotic himself who is called to produce this knowledge, since he alone
can have access to the hitherto unspoken of experiences which, in the past,
have determined his subjective position. Furthermore, the questioning of the
logic of the delusion and the placing into doubt of the delusional certainty will
surge forth in the psychotic himself, through his own productions of the
Unconscious. In this perspective, from the outset, we are asking the psychotic
to dream and to submit his dreams to analytic work as we question him about
the unfolding of the crises and the acts that take place during them, the acting
out, the accidents—in short, everything that is imposed upon him and
determined from a place other than that of consciousness or the delusional
interpretation. If the dreams that are presented are, at first, mixed up with the
content and the logic of the delusion, then the exigency of speech and the
constraint of the desire of the analyst—who continues his quest for the mental
representations, psychic experiences, and significant events that have
structured the subjective history—will trigger the working of the psychotic’s
Unconscious. Sooner or later, the Unconscious “responds” by producing
dreams, thoughts, and acts which progressively lift the censorship on a certain
number of phenomena and experiences which have been hitherto inaccessible
and have never found a form through which to be represented.
“As soon as one makes the unconscious into our ally, it speaks to us
through dreams and, at that moment, one learns what binds us to past
events.” Patient’s discourse
Through the thoughts, mental representations, visions, hallucinations,
memories, and childhood events that the dream gives access to—and which
take shape and are expressed for the first time—a series of specific subjective
experiences is revealed bit by bit. This series is connected by an unconscious
296
Cantin, L. (2009) ‘An Effective Treatment of Psychosis with Psychoanalysis in Québec
City, since 1982’, Annual Review of Critical Psychology, 7, pp. 286-319
http://www.discourseunit.com/arcp/7.htm
logic, and it exposes the structure of the fantasy to which the imaginary form of
the elements of the delusion and the object of the enterprise have been
responding. This singular and original logic, which the “re-construction” of
vivid historical events will have brought to light in the analytic work,
progressively comes to take the place of the delusional interpretation that had
previously been necessary in order for the subject to explain the surging forth
of phenomena that had no signification. The interpretation produced by the
delusion is not contested—it collapses because it has become obsolete and
henceforth useless. Thus, it is beginning with the psychotic himself, through
his Unconscious productions, that the delusion will be called into question.
The psychotic has then entered into a new work which is no longer indebted to
nor guided by the ceaseless and ineffective production of the delusional
interpretation. But the knowledge produced in transference by progressively
deconstructing the delusion also, by the same token, calls into question the
object of the enterprise and of the mental work the psychotic has been engaged
in. He is, therefore, confronted with the following situation: the markers and
foundations upon which the meaning of his life had rested are being
questioned, and must be completely rethought.
A renewed conception of transference
Willy Apollon has suggested redefining transference as “the love of the
knowledge of the Unconscious”. Such a conception still falls within the scope
of Lacan’s advances on the subject of transference, but has the advantage of
indicating a dynamic pathway through which it can become effective in the
psychotic’s analytic treatment. Until now, transference—somewhat falsely
associated with the stakes and failures of the oedipal experience—has
effectively been unable to find a parallel in the psychotic who, for his part, has
never entered into Oedipus. Lacan had already refocused the question of
transference by bringing it out of the relational and affective dimension that it
had been enclosed and trapped in after Freud. Reduced to the affective link
developed by the analysand for the analyst—and to the “reaction” triggered in
the analyst by the analysand—transference with the psychotic could be
nothing but “massive”. By defining transference as the subject supposed to
know, both as the knowledge supposed in the analyst and the subject
supposed in the knowledge of the Unconscious, Lacan underlined the
dimension of misunderstanding upon which the installation of transference
rests. The analysand, in an interested “error,” supposes the analyst to have a
knowledge about his Unconscious. Even more, he supposes an Other who
knows, an Other at the origin of that which is acting in him but without him.
But the psychotic, who arrives with a knowledge clad with unshakable
certainties, does not enter into this misunderstanding. The Other is the Other
of the delusion, the one who is at the origin of the Voices, and the analyst can
do nothing but be instructed by the psychotic’s experience and by what he
presents as the “knowledge” drawn from this experience.
297
Cantin, L. (2009) ‘An Effective Treatment of Psychosis with Psychoanalysis in Québec
City, since 1982’, Annual Review of Critical Psychology, 7, pp. 286-319
http://www.discourseunit.com/arcp/7.htm
From the point of view of clinical experience, making transference into
“the love of the knowledge of the Unconscious” opens another pathway for the
psychotic’s analytic treatment. The installation of transference doesn’t become
consistent with a position and a knowledge imputed to the analyst (un savoir
supposé à l’analyste) but rather with the psychotic’s own discovery of another
knowledge than the one produced by the delusion. It is in this way that the
dream—as a production of the Unconscious which leads the psychotic to give
form to that which has, since childhood, acted in him without his knowledge—
comes to create the breach that lets the psychotic catch sight of the existence
of another space within himself. The wager that we have made, and that the
psychotic has taken up, is that the production of a knowledge about what is at
work in the Unconscious was going to interest the psychotic so much so that
he would dedicate himself to it and orient his energies towards it without
recoiling before the continual requestioning that this work entails. The
psychotic enters into transference by acceding to this love of the knowledge
produced by the Unconscious. And we are able here, without a doubt, to better
grasp the constraint that transference imposes upon the work of the Thing:
that which had been working unbeknownst to the psychotic, and is now
finding a way to express itself, is becoming the object of a formulable and
transmissible knowledge which gradually calls the delusion into question. We
will say that the psychotic has entered into transference at the moment he
enters into this work and takes charge of it, waiting for his Unconscious to
produce the materials with which he sustains his work as an analysand. Entry
into transference, thus, is concomitant with the effects of calling the delusional
certainties back into question.
A different logic derived from the analytic work: transformations of the
fantasmatic constructions and a new subjective position
“But voices are the symptom that can lead to my cure if they are treated !
If I cannot talk about them, if I cannot approach them, tame them, try to
understand them, to understand what they are doing there, their reason,
their cause, if one does not treat them, imagine the consequences of a
psychosis.”
“The first thing to do is to learn how to know who you are, and then, above
all, to identify the logic behind the unconscious manifestations that, using
my past, were sabotaging my life.”
“Little by little, we reconstruct, then re-create our life.”
discourses
Patients’
The psychotic begins, from now on, to work from this new logic that is put into
place in his analytic work. He is interested, just like the analyst, in the
manifestations of the work of that which has been censored: symptoms, acting
298
Cantin, L. (2009) ‘An Effective Treatment of Psychosis with Psychoanalysis in Québec
City, since 1982’, Annual Review of Critical Psychology, 7, pp. 286-319
http://www.discourseunit.com/arcp/7.htm
out, staging of the crisis, failed acts, and repetitive forms and structures—in
short, everything that escapes the control of consciousness and which, because
it is not represented, returns to inscribe itself in the real of his body in the form
of acts or expressions which create a rupture in the social link. The symptom,
crisis, and acting out give access to a form taken in the real by that which does
not get expressed in speech.
The drive, here, responds to mental
representations that are inaccessible to consciousness, and which find neither
the words to be spoken nor a mode of expression that would be receivable in
the social link. This work, which submits what is inscribed and staged in the
real to the work of analysis, maintains the constraint of transference and
continues to solicit the Unconscious to produce dreams which bear the words,
formulations, and expressions that are needed to evoke the truth at work in the
Unconscious within language itself.
The knowledge derived from this new logic transforms the fantasmatic
constructions that had been supporting the delusion and the psychotic
enterprise, and modifies the subject’s position in the face of the experiences
and “events” of his history, which are at the origin of his psychosis and which
he revisits from a completely different perspective. Often, at these moments,
the psychotic grasps the effect these experiences have had upon him, how he
interpreted them, how he responded to them, how and on what historical and
accidental bases he constructed the delusional interpretation, and how he
finds himself profoundly implicated in what he had considered to be external
and accidental events and phenomena. It is this work of re-constructing and
reorganizing the entire mental universe, starting from decisive subjective
experiences, which will establish the definitive collapse of the psychotic
enterprise. It is here that the question of a true social rearticulation, beginning
from a new subjective position, is posed. Whatever forms may be taken by this
return to social and civic life (studies, work, volunteer work, arts, business),
the articulation, or link, to society can not be a “rehabilitation” or a
“reinsertion”. The psychotic’s analysis of the problems of humanity and the
mishaps of society, which had justified his refusal of the social link, were not
the source of his illness. It is not as a result of this lucidity that he is ill, but
rather, it is a result of the failure wherein he found himself unable to fulfill the
destiny he believed to be his—a destiny where he had to find, within himself
alone, “The” solution that would put an end to the chaos. Furthermore, the reestablishment of the social link cannot be a reintegration into the values,
ideologies, and beliefs of all kinds that the neurotic uses to console himself and
to forget. The psychotic’s articulation to the social link can only rest upon his
ethics. Thus, the problem he confronts is posed in the following terms: How
can he preserve the values and ethics borne within the object of the enterprise
in a production or form that would be both satisfying for him and receivable in
the social link. In this last part of the analytic treatment, the psychotic
assumes full responsibility for what happens to him and faces the
consequences of his new subjective position in his relations with others, with
family, and with society. Thus, he reconsiders and reconstructs all spheres of
299
Cantin, L. (2009) ‘An Effective Treatment of Psychosis with Psychoanalysis in Québec
City, since 1982’, Annual Review of Critical Psychology, 7, pp. 286-319
http://www.discourseunit.com/arcp/7.htm
his life on completely different bases than those which founded his psychotic
work.
The treatment’s structure as a whole
The work of the analytic treatment in which the psychotic is engaged is
inscribed in a treatment’s structure as a whole, consisting of a collection of
services which are related to the psychoanalytic clinic, its objectives, and its
effects. A highly precise framework, put into place by the very organization and
functioning of the Center, maintains the ethical conditions of a treatment
founded on speech, and thus forms an integral part of the treatment’s structure
that creates the analytic field. I will begin by defining this frame within which
these services are inscribed.
The framework of the treatment’s structure
“The Center is the laboratory of our social life. The relationships that we
manage to establish here, whether it is with the intervenant, with the other
patients, with the psychiatrist, all of these relationships are a laboratory.
One acquires things in this laboratory that, afterwards, it is possible to
realize within the larger collective.” Patient’s discourse
As we mentioned above, the Center is located in an old house, situated in an
active urban environment. The house is open, and everyone moves around
freely there. The relations with patients are regulated by the necessity of
speech. The Center has no isolation chamber, no means for restraint, no
attendants who can intervene to physically control a psychotic in crisis, and no
in-house medication, not even emergency neuroleptic medication.
Each
patient remains responsible for the medication that has been prescribed to
them, and which they must manage on their own. At the time of admission,
everyone receives a text presenting the rules of the Center’s functioning. Some
basic rules, the same ones that prevail in society, define the frame within
which coexistence in the mutual respect of all becomes possible, and state the
prohibitions that guarantee the prevalence of speech and negotiation over the
acting out and violence. From the moment he enters the Center, the patient is
solicited with responsibility he must assume for behaving like a citizen. These
functional rules, to which all—patients and staff members alike—are
submitted, establish the first symbolic markers encountered by the patient,
and inscribe the Center in a public space by connecting it to the exigencies of
civic life. Whatever his problems or illness, the patient will have to respect the
social link’s rules of the game.
But what is more, beginning with his first contacts with the Center—
whether it is in the course of the first interview with the admissions Committee,
or with the clinical intervenant who will have received him and taken him to
300
Cantin, L. (2009) ‘An Effective Treatment of Psychosis with Psychoanalysis in Québec
City, since 1982’, Annual Review of Critical Psychology, 7, pp. 286-319
http://www.discourseunit.com/arcp/7.htm
visit the various locations—the patient will discover that everything must pass
through speech. He will have to speak, to say what is on his mind, to
participate in the decisions that concern him, and to commit himself to
respecting the agreements entered into with the team who provides his follow
up. Even in the course of periods of crisis or psychotic disorganization, which
in the past had sent him to the hospital, he will have to maintain a speech
connection with us if he wishes to go through these times of crisis at the
“388”—without the frame, means, and confinement that had previously been
necessary. It is necessary to take stock of this responsibility to which the
psychotic is summoned, with, of course, the support of the Center’s entire
team. The commitment solicited in the psychotic takes very concrete form in
an open place such as ours, which offers no other tool for intervention than
speech and the credibility granted to this speech by the link of trust
established with the staff members.
“There are the agreements. What’s nice is that every six months, you
review the intervention plan together with the intervenant, the doctor, and
the social work in order to decide what you are going to do. Beforehand,
you’ll reread the one you made six months ago. You can see the guiding
thread, what you succeeded in, what you didn’t succeed in, and what
must be worked on again. It’s like a path that you outline on your own.”
“The treatment plan is the bridge between the cure and your everyday
reality.” Patients’ discourses
In this way, from the very first encounters with the team responsible for his
follow-up, the patient will be called upon to actively participate in his treatment
plan and to respect the agreements he will have discussed, negotiated, and
verbally entered into with them. Within this framework he will also establish a
schedule of activities and art workshops, which are chosen in relation to his
treatment objectives. The verbal “agreements”, once they are decided upon as
a group, constitute a third object which has authority and primacy over the
position of each one of the concerned parties. If the patient wants to change
the terms, he will have to renegotiate them with those with whom these
agreements had originally been undertaken. Even when the psychotic is in
crisis, disorganized, hallucinating, and delusional, this same manner of
functioning will be maintained. It is altogether remarkable to see the extent to
which the psychotics are sensitive to and reassured by the primacy accorded to
speech and to the agreements established through discussion and negotiation.
For example, we have seen one such patient residing at the Center during a
crisis who, in the middle of the night, decided that he wanted to leave and
came downstairs to discuss it with the staff member instead of simply taking
the exit leading to an external staircase, which was accessible from his thirdfloor room.
301
Cantin, L. (2009) ‘An Effective Treatment of Psychosis with Psychoanalysis in Québec
City, since 1982’, Annual Review of Critical Psychology, 7, pp. 286-319
http://www.discourseunit.com/arcp/7.htm
A symbolic frame, thus, is substituted for physical limits.
The
establishment of rules for coexistence that all are urged to respect, just like the
primacy accorded to language and speech, institutes a symbolic authority and
differentiates it from power. Instead of the relations of force experienced,
rightly or wrongly, by the psychotic in the various hospital situations where the
very structure of the place feeds a paranoid position, the organization and
functioning of the Center founds authority upon the constraint of language and
the credibility granted to the other. The psychotic can only be reassured by
this restoration of a symbolic order since he suffers precisely from the
imaginary hold of an all-powerful Other of which he is the persecuted,
sacrificed, or assaulted object. Here again, our initial hypothesis has been
remarkably confirmed. Contrary to the predictions of those who believed it to
be impossible to treat psychotics in crisis with so few medical means, in such
an environment, and thought the Center would last only a few months, the
psychotics have provided a remarkable clinical lesson. In twenty-seven years,
nothing has even been broken in the house, including the fragile stained glass
windows that should have been the first to disappear… On the contrary, the
psychotics were calmed and have expressed it: they no longer had to struggle
against a treatment that they had previously experienced as aggressive, and
which placed them in a paranoid position.
A division of the spaces inside the Center also contributes to supporting
the symbolic frame of the treatment. The first floor gathers together the public
spaces, while the second floor becomes the private space that consolidates the
consultation offices of the psychoanalysts and psychiatrists. As for the third
floor, which is reserved for bedrooms, it represents an intimate space. Only the
psychotics residing at the Center during intensive treatment of the crisis have
access to it, and only for the period of time when they are residents. This
division of spaces is significant. The patients will have to respect the public
spaces by behaving in the same way there as is appropriate in society.
Inappropriate behaviors, bad language, topics which are too personal, and
delusional discourses which are unpleasant for others will not be acceptable
there. It is in these places—living rooms, the waiting room, the kitchen, the
dining room—that the psychotic must be “with others” and constrain himself to
enter into the negotiation that is necessary for coexistence. He is supported in
this venture by the clinical intervenant, whose task is to work towards restoring
the psychotic’s articulation to the social link. Of course, this constraint is only
possible and effective because the psychotic disposes of several other places
where he can address an intimate speech, with the analytic cure, of course,
being the privileged site for this. This spatial distinction supports an internal
division that gradually comes to be made within the psychotic between, on the
one hand, public discourse, and on the other hand, the subjective speech he
can address to someone who is not afraid of hearing it. It is not because the
intervenant is bothered by the psychotic’s discourse and words that he prevents
their expression in public. For, it is only on this condition that the intervenant
will find the right words, manner, and tone to situate his intervention in a
302
Cantin, L. (2009) ‘An Effective Treatment of Psychosis with Psychoanalysis in Québec
City, since 1982’, Annual Review of Critical Psychology, 7, pp. 286-319
http://www.discourseunit.com/arcp/7.htm
perspective that would not simply be construed as defensive. His act aims at
the restoration of the social link, which assumes an adherence to that which is
receivable as discourse within society. The rules that prevail in public also
support another place, in opposition to the ascendancy of the mental space
within which the psychotic is withdrawn and enclosed.
“When you’re residing at the Center, you’re not out of touch with reality.
You’re not disconnected from normal functioning. There are no means of
restraint, either physical or chemical. You have chores to do, the dishes,
cooking…Even those who are completely in psychosis have chores to do
anyway. This helps you stay in the concrete, to not completely lose your
footing. The intervenants try to speak with you to understand how you
feel and what’s wrong. Even if what you say doesn’t make any sense,
they try to help you understand what is happening to you. And finally,
you realize that certain things are making you feel unwell, and then how to
solve them.” Patient’s discourse
This other place, regulated by social life, is also represented by the exigencies—
which are upheld for all patients, even the most disorganized ones, and even
during periods of crisis—to participate in the activities of daily life (the upkeep
of their rooms, the preparation of meals, the division of household tasks,
cleaning their bedding when they leave the residence, etc). As anchoring points
in a common reality, these activities obligate the psychotic to the negotiation
that coexistence requires, but they also represent the necessary maintenance
of a socially acceptable position—just as much in what concerns behavior and
words as in what relates to bodily hygiene, politeness, and considerate
attitudes towards others. Naturally here, the psychotic finds himself forced to
exit the mental universe which captivates all of his time and his entire mind.
But in a treatment situation which is not anonymous like a hospital, where the
psychotic is faced with other patients who he will continue to walk along side,
and who will continue to be his companions at the end of the crisis, this
exigency takes on both an ethical and an aesthetic dimension. Ethical because
the psychotic, even in crisis, is called to assume full responsibility for his acts;
aesthetic because, in the aftermath of the crisis, he finds himself obligated to
preserve a position, attitude, mood, and appropriate words which he will not be
embarrassed by in the face of his companions.
The psychotic, thus, always remains responsible for his acts. Here
again, twenty-seven years of experience in the treatment of psychotics will have
been the occasion for a striking lesson.
Under special circumstances,
especially in the first years of the Center’s existence, the directorial team
brought together all of the patients and personnel for what we called “special
meetings,” which had become necessary in order to correct an observed
relaxation in respect for the Center’s rules. These meetings—one of which, for
example, dealt with the prohibition against all forms of the expression of
aggressivity, even verbal—were the site of open and particularly eloquent
303
Cantin, L. (2009) ‘An Effective Treatment of Psychosis with Psychoanalysis in Québec
City, since 1982’, Annual Review of Critical Psychology, 7, pp. 286-319
http://www.discourseunit.com/arcp/7.htm
discussions with the patients. The directorial team was reminded there that
the very existence of the Center, its way of functioning, and the possibility of
continuing to offer a psychoanalytic treatment founded on speech depended
essentially upon them and their decision to make sure that the proposed
symbolic frame be upheld. To the psychotics who gave the excuse that their
bad language or inappropriate behaviors were due to their psychic state,
certain others retorted “that it did not matter since we always know what we
are doing, even in the depths of the crisis.” In fact, for us, everything depended
upon the adherence of each to the symbolic frame, which outlines an open
environment such as our own. Without this, the treatment—particularly,
treating the crisis outside of hospital walls—would be rendered impossible.
The psychotics were called to this commitment, but above all, they were faced
with the fragility of a symbolic authority, an authority that renounces physical
constraint and only finds its legitimacy and foundation in the recognition and
credibility afforded to it. This confrontation with, or rather, this access to the
inconsistency of authority is fundamental for the psychotic. It is here that he
has the experience of another space than that of the relations of force and
power which govern the imaginary universe in which he is struggling. This
space is regulated, instead, by an initial consensus wherein he, like everyone,
is called upon to renounce all forms of violence. It is important to emphasize
the way in which the directorship’s “true” position, without any trickery, is
essential here in order for the psychotic to truly undergo this decisive
experience. The fragility of the directorship’s, and the installed framework’s,
hold on authority can be nothing other than very real. For example, the
decisions to have no on-location recourse to physical means, no alarm bells in
our offices, and not even emergency medication, were taken in the full
knowledge that any such recourse would lead the psychotics to push back
against us in order to verify the authenticity of our positions and our
credibility. Instead, it was necessary to provide the unavoidable experience of
an authority which rests only on language and the symbolic, and which solicits
the psychotic’s participation and engagement in maintaining the conditions of
possibility for such an authority as well as the psychoanalytic treatment it
makes possible.
The services that constitute the treatment’s structure
The treatment’s structure functions through a set of services that frame the
effects of the analytic experience in which the psychotic is engaged and ensure
the comprehensiveness and continuity of the treatment, from the moment the
psychotic enrolls at the Center until his departure—including, of course,
undergoing the treatment of the crisis. This comprehensive treatment
articulated to the analytic treatment includes, furthermore: psychiatric follow
up with a multidisciplinary team led by a psychiatrist who is also a
psychoanalyst, and who will supervise the totality of the treatment throughout
its development; long-term psychoanalytic follow up provided by the clinical
304
Cantin, L. (2009) ‘An Effective Treatment of Psychosis with Psychoanalysis in Québec
City, since 1982’, Annual Review of Critical Psychology, 7, pp. 286-319
http://www.discourseunit.com/arcp/7.htm
intervenants, who are all trained in the psychoanalytic approach developed by
Gifric; art workshops run by artists who have no connection to the clinic or to
psychoanalysis, and an activities program that aims at the patient’s
rearticulation to the social link; and finally, support for the families. Upon
entering the Center, the psychotic will form a team with a psychiatrist and a
clinical intervenant who is responsible for his care, and together with them he
will establish the direction of the treatment—from the first initial objectives,
which are targeted and revised according to need, until the putting into action
of the social rearticulation projects which will sign the end of the treatment.
But simply enumerating these facets of the treatment does not account
for its singularity. Their articulation to the progression of the analytic work in
which the psychotic is engaged is simultaneously decisive for the objectives
targeted by the treatment, the ways in which it is applied, and the very position
of the clinician. The psychiatrist, for example, in addition to ensuring a topnotch psychiatric practice and directing the treatment team, has a precise
function that could not be fulfilled by a psychiatrist who is not also an analyst.
He has the task of watching over and maintaining the psychotic’s physical and
psychic integrity against the destructive effects of the work of psychosis. In
order to do so, he must have access to the psychotic’s subjective experience
and to the subject of his preoccupations and his delusion. He must know the
stakes of his analytic work, its stages, and its critical points so that he can
adjust the psychiatric follow up accordingly and foresee any necessary changes
to the treatment plan. The psychiatrist at the 388 must be able, therefore, to
both provide psychic treatment and inscribe his act within the analytic field.
Moreover, in a Center like the 388, which opens onto the whole of
society, all of the psychiatrist’s interventions, recommendations, and treatment
proposals reply upon speech, negotiation, and discussion with the patient.
Thus, everything depends upon the link of trust that is established with the
psychotic, which is founded upon the credibility that each affords to the other.
The continual implication and participation of the psychotic, which is
presupposed by such a framework, contributes to maximizing the effects of the
psychiatric treatment.
Such is the case, for example, with the use of
medication. It no longer constitutes the heart of the treatment, but it is the
object of discussion and it comes into play as a support for soothing, calming,
and helping to manage the symptoms of psychosis in such a way that the
continuation of analytic treatment or of on-site treatment of the crisis remains
possible. Not only does medication take on an entirely different meaning, but
we often remark that lower doses of medication than those prescribed in
hospitals are necessary to obtain the desired effects. Similarly, it is the
psychotic’s engagement in maintaining a link of speech with us—giving us
access to his mental preoccupations, his delusional ideas, and hallucinations—
during the crisis that allows us to make the pointed and constant evaluation
which is necessary for treating it outside of hospital walls, and without the
constraints that had been necessary for these very same patients when they
were treated in a hospital setting. And so, deploying the psychotic’s speech,
305
Cantin, L. (2009) ‘An Effective Treatment of Psychosis with Psychoanalysis in Québec
City, since 1982’, Annual Review of Critical Psychology, 7, pp. 286-319
http://www.discourseunit.com/arcp/7.htm
within the analytic field he is engaged in at the 388, provides the psychiatric
practice with means that it would not otherwise possess, especially by
permitting a particular acuteness in clinical evaluation and judgment.
“I was awoken by a voice in my dream that said, it was someone who
directly said to me that I was in a psychosis. It was nighttime and I woke
up with that. What I heard was a dream, it was not a voice, so I called the
Center, and I said: “I am a bit upset, I do not feel well, I have the
impression that I must be veering toward psychosis.” I talked with the
intervenant and I told him something that I had said in psychoanalysis.We
reflected a bit on it, he helped me to further my reflections; he reminded me
of another time when I had thought something similar and what had
happened: that really put me back into context! It is as if that allowed me
to regain hold of myself and to understand the meaning of what was
happening, and when one understands the meaning of what is happening,
it is easier to keep one’s feet on the ground.” Patient’s discourse
As for the clinical intervenants, they are responsible for the long-term
psychoanalytic follow up. As a true landmark for the psychotic through the
entire course of his treatment at the center, the clinical intervenant provides—
both at the Center, and in the community—the patient’s follow up on a daily,
weekly, or monthly basis depending upon the development, stages, and critical
moments of the treatment. His role is inscribed within two principle axes: first,
accompanying the psychotic through the traversal of the crisis, assuring the
specific clinical work that it supposes before, during and after the crisis, and
second, restoring a believable symbolic space and a satisfying relation to the
other in the social link. In each of these two main axes, the follow up is
psychoanalytic insofar as it is a matter of assisting the psychotic in his work of
applying the knowledge that was constructed in the analytic experience. The
clinical intervenant, who is a privileged witness to the psychotic’s evolution in
the course of treatment, supports and compels this necessary connection
between the knowledge drawn from the analytic experience and the concrete
changes they lead to in the psychotic’s life. Whether it is in the unfolding of
the crises, whose form and content will evolved in the course of the treatment,
until they fade away completely once that which conditioned them will have
been solved; whether it is in the new positions that the knowledge deriving
from the analytic experience imposes in relations with others, as well as in
social and affective life; or whether it is through the elaboration of a social
project articulated to the ethical stakes linked to the singular desire that the
psychotic discovers as his own—in all of these cases, the clinical intervenant
accompanies the psychotic in the emergence and exploration of a new
subjective position which is consistent with the effects, changes, and
displacements that the analytic work has led to.
306
Cantin, L. (2009) ‘An Effective Treatment of Psychosis with Psychoanalysis in Québec
City, since 1982’, Annual Review of Critical Psychology, 7, pp. 286-319
http://www.discourseunit.com/arcp/7.htm
“When you do a psychoanalysis, your unconscious needs an outlet. And I
think that through the art workshops, this unconscious in the process of
working can at least find some respite.” Patient’s discourse
Throughout this progressive work, the activities and art workshops on the
Center’s schedule will have simultaneously supported the restoration of the
relation to the other in the social link, allowed for the channeling of psychic
energy into action or the production of an object—whatever it may be, and
initiated the discovery of a space where the subject’s act of creation assuages
and overcomes the absence, or defect, of the words needed to express the
subject’s experience.
The art workshops are often the occasion for an
astonishing production that surprises the artists who direct the workshop just
as much as the patients themselves, who are discovering hitherto unforeseen
talents. In this way, these activities regularly bring the staff members to
recognize of all of the creativity, reflection, and lucidity shown by certain
patients whose clinical state did not hint at any such productions.
A management founded on psychoanalytic ethics
“The administrative and clinical framework is intimately interconnected,
very elaborate, and forms an integral part of the therapeutic strategy.
The program was conceived, and…the management was thought through
and applied in relation to this program.” Evaluator’s report, 2002: 18-20
Another characteristic of the Center, inseparable from the success of the
treatment, lies in its original administrative and clinical management, which is
thought through and created to be “tailor-made” for assuring the maintenance
of the frame, conditions, and practices that are essential for psychoanalytic
treatment.
The principles
Two main principles drive this type of management. The first is the necessary
implication of psychoanalysts within the clinical-administrative structures, and
their powers of decision therein. This is a decisive element of the treatment’s
structure. The Center’s management is framed by psychoanalysts who have full
authority over all decisions touching upon clinical programming, personnel
management, the determination of working teams, as well as any other
administrative measures that have a direct or indirect impact upon the
treatment and its development. The psychoanalysts, then, are the guarantors
of preserving the clinical orientation, in so far as they ensure that the
objectives and stakes of the clinic of psychosis, as well as those of
psychoanalytic treatment, take precedence over all other considerations. This
initial binding to the imperatives and aims of the treatment confers a believable
307
Cantin, L. (2009) ‘An Effective Treatment of Psychosis with Psychoanalysis in Québec
City, since 1982’, Annual Review of Critical Psychology, 7, pp. 286-319
http://www.discourseunit.com/arcp/7.htm
foundation upon the structures of authority, and connects everyone to an
ethics that guides their practice and founds their clinical act on reasons that
transcend any possible personal positions—whether narcissistic, or related to
interest groups (professional or union related)—which are always liable to
hinder the pursuit of the clinical aims upon which the patients’ health
depends.
A second principle orients the practice of management at the “388”. At
the “388”, Gifric substitutes a “performance obligation” for the “due care”
obligation that the professional is normally bound to. In general, the “clinicaladministrative evaluations” of care-giving programs, such as the one the “388”
underwent in 2002, do not evaluate practices according to the obtained clinical
results. Rather, they aim at verifying that the services and care being offered
correspond to the practical guidelines of the professional bodies as well as to
institutional and governmental norms. In fact, this is an approach that
ultimately risks becoming focused on the professional and the organization of
the institution: is the practitioner conforming to the norms established by his
professional governing body, as well as to those of the very institution that
must itself also answer to exigencies and functional rules of all sorts, which
end up overriding the clinical necessities and effective results that are being
awaited by patients? The exigency of conforming to the norm is substituted for
an ethics commanded by a commitment to clinical results. All clinicians are
aware of the danger of seeing their act determined by constraints other than
those put forth by the logic of the particular dynamic of a patient. This is the
perverse effect of the nonetheless necessary framework of professional
practices, and the no less important evaluation of care-giving programs.
While still respecting and submitting ourselves to these external
obligations—as is made clear by the numerous evaluations the Center has
undergone in its twenty-seven years of existence—we have attempted to create
a clinical-administrative framework and managerial style that is essentially
based on the objectives of the psychoanalytic clinic and psychoanalytic ethics.
The expectation of a precise result from the treatment has become the exigency
that compels the psychoanalysts, psychiatrists, and clinical intervenants. The
clinical-administrative management, in all of its various parts, is completely
reoriented around the clinical results that overdetermine its goals and methods
of application. It becomes strictly a management of the clinic, reducing the
administrative dimension—which is normally attached to the notion of
management—to the practices which support clinical decisions.
Before
anything else, it aims at the follow up, analysis, and continuing evaluation of
the clinical practices and their results in a way that maintains the services and
conditions that guarantee their success, or that corrects them when necessary.
To this end, a number of structures and tools have been created and put into
action by Gifric.
308
Cantin, L. (2009) ‘An Effective Treatment of Psychosis with Psychoanalysis in Québec
City, since 1982’, Annual Review of Critical Psychology, 7, pp. 286-319
http://www.discourseunit.com/arcp/7.htm
The structures and tools of clinical-administrative management
The clinical Observatory, created in the first years of the Center’s functioning,
constitutes the core instrument that allows for all of the following: follow up of
the collected practices of the clinical intervenants and psychiatrists, and their
evaluation with respect to the anticipated results; follow up of the series of
interventions and acts undertaken with a patient; tallying the rate of use for
each of the Center’s services; follow up of the evolution of the treatment for
each patient on the basis of objective indicators, such as a reduction in
hospitalizations, use of the Center’s residence for treatment of the crisis, their
level of autonomy, social involvement, return to civic life, etc.
These databases can be examined from a variety of angles. They allow
us to track and analyze the development of a patient or group of patients, to
isolate the standard routes, crucial moments in the logic of the treatment,
particularities presented by difficult cases, and failures of the treatment. In
short, they allow us to isolate a certain number of clinical questions which the
psychoanalysts examine in order to grasp their theoretical and clinical stakes,
as well as to make modifications in the methods of treatment when they are
called for. The clinical Observatory also serves to interrogate the set of
interventions and acts that have been performed, the types of services used by
the patients, and even some precise data such as attendance at activities,
number of phone calls, or usage of the Center at various precise moments of
the day, evening, or night. These analyses are never performed with the
intention of controlling the personnel. Instead, they give us an objective
portrait of a situation that has already been brought to light by the clinical
intervenants, psychiatrists, or the Center’s directorship. These analyses also
bring out certain dimensions of our practices, and even the modifications and
slippages within them that have taken place without our knowledge.
Additionally, the clinical Observatory has sophisticated computing tools
that allow for a dynamic utilization of theoretical concepts and clinical data on
psychosis, on the psychoanalytic clinic, on implicit knowledge developed by the
clinicians and clinical intervenants as their field practice progresses and on
advances in theory. A structure organizes these diverse pieces of information
and knowledge in a way that makes them simultaneously accessible and
transmissible for teaching, for training new personnel, and for sharing
expertise with other professional teams.
Finally, research on familial and parental structures—which was
conceived and carried out at Gifric by Willy Apollon—lends support to the work
of the ethnoanalyst who, alongside the patients and their families, collects
information about kinship structures. This information is primarily put at the
disposal of the team responsible for a patient’s treatment, where it helps to
clarify the broader psychodynamic situation within which the psychotic is
evolving, but it also provides a set of meaningful data for the development of
theoretical and clinical research on psychosis and its psychoanalytic
treatment.
309
Cantin, L. (2009) ‘An Effective Treatment of Psychosis with Psychoanalysis in Québec
City, since 1982’, Annual Review of Critical Psychology, 7, pp. 286-319
http://www.discourseunit.com/arcp/7.htm
Besides the clinical Observatory, two clinical seminars on the treatment of
psychosis are held at Gifric. The first, which meets weekly, gathers together
the psychoanalysts who are responsible for the psychoanalytic treatment of
psychotics and the supervision of complex cases. This seminar, which is
ongoing since the beginning of the Center, is a place for reflections,
questioning, elaboration, and development of the various theoretical and
clinical dimensions implicated in the analytic treatment of the psychotic. It is
here that the theoretical advances, the renewal of certain concepts, the
modifications of analytic technique, and the internal logic and stages of the
analytic treatment are established and discussed. This is also where the
specific difficulties encountered in the unfolding of the treatments are worked
upon. The analysts’ seminar is, thus, the site of a continual development of
the theory, which is always put to the test of the teachings, problems, failures,
and successes that are brought to light, as much in the clinical practice as in
the data of Gifric’s Observatory. A second clinical seminar, which meets bimonthly and deals with psychosis in a broader fashion, brings together the
psychiatrists and some clinical intervenants who are directly implicated in the
treatment of the psychotics, in the same way as clinicians in training.
Furthermore, the clinical-administrative management at the 388 is
implemented through an original structure that was conceived in order to
ensure the connection between administrative decisions and the interests of
the clinic. One particularity of this structure is certainly the way it places the
directorial team in direct connection, with no intermediary authority and in a
continuous fashion, with the group of psychiatrists, psychoanalysts, and
clinical intervenants involved in the follow up and treatment of patients.
Obligatory meetings, both daily and weekly, between these different groups
ensure the follow up of treatments, their evolution, the coordination of
interventions, and the discussion of treatment plans. Additionally, a weekly
clinical meeting of all personnel as well as the directorship is run by a
consulting psychoanalyst, from outside of the Center, who is responsible for
the supervision of complex cases, the establishment of the theoretical
framework of the psychoanalytic treatment, and the continued training of
personnel. This is the place where the main principles of the treatment are
produced, and their common underlying clinical approach is developed. On all
of these different levels, the directors’ presence and regular work with the
principal actors in the clinic maintains the priority of clinical concerns over all
other considerations when administrative steps or measures must be taken.
This allows the analysts and directors to be informed of the different situations,
questions, or clinical problems that orient and determine the managerial
decisions.
Two mechanisms which allow for feedback on the Center’s general
functioning constitute the second important characteristic of the management
structure. First, tri-monthly clinical reviews meetings assemble the personnel,
psychiatrists, psychoanalysts, and directors for a half-day. They are an
opportunity for pause and feedback about the clinic in general, the
310
Cantin, L. (2009) ‘An Effective Treatment of Psychosis with Psychoanalysis in Québec
City, since 1982’, Annual Review of Critical Psychology, 7, pp. 286-319
http://www.discourseunit.com/arcp/7.htm
organization of services, the problems encountered by the clinical intervenants,
certain elements of the Center’s programming, or various aspects of the
evolution of treatments such as are revealed by the clinical Observatory or
inquired about by the psychoanalysts. These meetings—which are always held
someplace other than the Center—are an invaluable time for discussion, and
are essential for maintaining the clinical and ethical orientation to with each of
the actors is bound. They always conclude with the decisions that have been
made by directorship, touching upon the adjustments, corrections, or changes
to be made in the practices or programming, as well as how they are to be
carried out.
The second mechanism for practical feedback is put into place through
the evaluation meetings with each member of the personnel. These individual
interviews are led by the directorial team and take place approximately once a
year. They are an opportunity for the intervenants to take stock of their work,
their difficulties, their evaluation of the clinic, or any other aspect of the
Center’s functioning that they would like to discuss directly with the directors.
For the directorship, these exchanges provide an opportunity to gauge the
general functioning of the Center by shedding light upon some of its important
dimensions, which would be otherwise inaccessible. For the staff members as
well, it is a moment that they anticipate and deem to be essential. They speak
freely during these meetings, as much about their difficulties as about their
analysis of certain situations, without fearing that their words will lead to any
reprisals. These evaluation interviews, therefore, are not part of any selection
or grading process for the staff. The stability of the current team bears witness
to this, as the majority of them have been at the Center since it opened.
Finally, the Center’s psychoanalysts provide individual supervision of
each of the clinical intervenants. This supervision is not related to the control
and evaluation of the clinical act. Instead, it was conceived as a mechanism to
allow the intervenants to identify the effects aroused in them by certain
situations or particular clinical dynamics in a way that differentiates them from
that which concerns the patient’s own problematic. This work helps to avoid
situations wherein the intervenant’s clinical acts and interventions are based in
their own affective reactions and subjective unconscious, instead of being
founded on the patient’s position and the specific treatment objectives. The
supervision here is not a psychotherapy for the staff members but rather a
place for free speech, never repeated or used against them where the work
mainly focuses on the quality of their clinical acts with the patients.
...A psychoanalysis with clinical results
“I think that the subject is us and that the first thing which the
psychoanalytic approach brought me was responsibility for my own life.
The responsibility of being “the conductor of an orchestra,” as it were.”
311
Cantin, L. (2009) ‘An Effective Treatment of Psychosis with Psychoanalysis in Québec
City, since 1982’, Annual Review of Critical Psychology, 7, pp. 286-319
http://www.discourseunit.com/arcp/7.htm
“I believe that it is every single time that we provide the solution to the
problem.”
“I would say that psychoanalysis has brought me healing.”
“The 388 is not a family, it is a Center for treatment. The 388 does not
pretend to give something to people, because they never had it. It provides
tools so that these people can go look for what they need.” Patients’
discourses
Faced with the now recognized insufficiency of pharmacological and hospital
methods in the treatment of schizophrenia and related psychoses, a variety of
treatments have been developed which are recognized as necessary
supplements. Among these, the new cognitivist psychotherapies—deriving
from advances in the neurosciences—are redefining the very meaning of
psychotherapy. Fundamentally centered on correcting active symptoms—
delusional ideas and hallucinations—by starting from the data of perceptive
reality and their interpretation by the mind, psychotherapy is now more clearly
exhibiting its objectives of readaptation and reeducation; objectives which, in
fact, it has perhaps always pursued with the psychotic, to varying degrees of
success.
As for psychoanalysis, it is not a psychotherapy and should not be
compared to one in its objects, nor in its means, nor in its results. It is part of
a different field than that of the reality produced by perception and
consciousness. Psychoanalysis is interested in pure productions of the mind—
mental representations with no link to “reality”, fantasies, and hallucinations—
which, censored in the Unconscious, trigger and put to work an internal energy
that the individual experiences as foreign to himself and outside of his control.
This is what Freud called the drive, an energy both psychic and somatic, an
inexhaustible fuel put to work by a reality which is not that of the external
world. It is in this other place, this Other Scene, where what determines a
subject is not found in his link to the environment, that psychoanalysis works.
In the analytic treatment, the psychotic is called to account for what is acting
in his Unconscious unbeknownst to him, and to accept to rely upon this in
order to find a mode of expression for what is censored and active in him other
than just the symptom, acting out, or crisis he had hitherto used to express
himself. Putting the Unconscious to work, through the dream and the analysis
of the symptom, produces a singular knowledge about a unique experience
from which the psychotic constructs his own proper way of managing the
hallucination and the drive. The delusional interpretation, which was trying to
manage the manifestations of the Unconscious through an interpretation
deriving from consciousness, becomes useless. The solution, thus, does not
follow from an understanding elaborated by consciousness or some
interpretation of the psychotherapist—cognitivist or not—but necessarily
derives from the productions of the Unconscious, which are constrained to a
312
Cantin, L. (2009) ‘An Effective Treatment of Psychosis with Psychoanalysis in Québec
City, since 1982’, Annual Review of Critical Psychology, 7, pp. 286-319
http://www.discourseunit.com/arcp/7.htm
particular work by the act of the analyst.
Psychoanalysis, then, is
distinguished from psychotherapy by its objects, its aims, and its working
means. But it is also separated from it by the position of the analyst, which
has no other support than the work of the Unconscious and the ethics of the
analysand who is confronted with the knowledge produced therein. The results
of the analytic experience that the psychotic is engaged in go well beyond a
readjustment to external reality. The very position of the subject is modified in
the face of what was at the origin of his psychosis and his symptoms. From
now on, he knows what was working in him and can consequently take up a
position and recover a freedom of action. Of course, this profound change has
concrete consequences for the rediscovered possibility of participating in an
active social life. This is what the psychotics themselves bear witness to, as
much in the development and progress they display—which is identifiable by a
third party—as in the capacity they possess for giving their own verbal account
of the analytic experience, its logic, and its consequences.
Indeed, on many occasions over the course of these last years, the
patients have desired to express their opinion about the treatment offered at
the 388, the psychoanalytic treatment and the work that it entails, as well as
the specific effects and concrete changes the psychoanalysis has produced in
their existence by allowing them to retake possession of their means and
rediscover pride and respect for themselves in an active life in society. They
have spoken publicly on certain occasions, particularly with the governmental
authorities and different evaluators or researchers who have come to meet with
them in order to get their opinion on the 388’s services, the psychoanalytic
treatment, or some other sensitive issue concerning the effects of the
treatment. On each of these occasions, their testimony has been striking for
those who have had access to it. The truth, quality, and depth of their
analyses of the various aspects of the treatment, which were stated with
incredible lucidity—quite unexpected, for some people—have made each one of
these moments unforgettable, inscribed in the history of the 388.
The words of the patients cited through this article are, in part, extracts
from individual testimonies and group discussions that were held in
preparation for a workshop dedicated to the 388’s patients, which took place at
the international conference on the treatment of psychosis organized by Gifric
in Québec City during May of 2008. The rest come from a group interview
granted by the patients to a journalist a few years ago.
In conclusion, the conceptions of schizophrenia and the psychoses which
are presupposed in the treatments proposed and recommended by the current
trends in psychiatry and psychology cannot be passed over in silence. Insofar
as they are understood as “brain diseases”, the psychoses can do nothing but
await the advances in research and the arrival of new and effective biological
treatments. In such a context, the efforts on the periphery of medical
treatment have to concentrate on providing care, family support, reeducation,
and rehabilitation, like so many palliatives necessary for improving the quality
of life for psychotics. These stances are not new in psychiatry, even if
313
Cantin, L. (2009) ‘An Effective Treatment of Psychosis with Psychoanalysis in Québec
City, since 1982’, Annual Review of Critical Psychology, 7, pp. 286-319
http://www.discourseunit.com/arcp/7.htm
pharmacology, in a more obvious way than ever, is in the process of completely
replacing the psychic treatment for which the psychiatrist should nevertheless
be trained. But it is surprising, to say the least, to see psychology following in
suit with these medical trends. On the one hand, with the development of
diagnostic approaches where the evaluation of a clinical problematic is now
reduced to the enumeration of a set of symptoms, each one has to be treated
by a precise type of therapy or intervention. Naturally, such an approach is
not unreminiscent of the now-accepted psychiatric practice of the
polypharmacy, where each symptom is targeted and treated by a specific
“molecule”. On the other hand, psychology is clinging more and more to the
neurosciences and, as it tries to fill the terrain left vacant by psychic treatment,
it is developing a psychotherapy which is nevertheless entering, in the end, into
the service of rehabilitation.
We are also entitled to question the bases upon which the assertions and
positions assumed by the various psychiatric and psychological practice
guidelines rely, and which make psychoanalysis into an inadvisable, even
dangerous, approach with psychotics.
Psychoanalysis was created and
thought through starting from the problematic of neurosis, which determined
its methods and techniques for application. But the fact remains that Freud
left us a metapsychology which still to this day comprises the most complete,
and thus far unsurpassed, theory about the foundations and functioning of
mental life and the human psyche. Himself recognizing the limits of applying
psychoanalysis with psychotics, he hoped that new research after him would
supply the modifications necessary for the analytic technique to be capable of
treating psychosis. This is what we have devoted ourselves to for the past
twenty-seven years, with new clinical results that are both indisputable and
verifiable. One should not prohibit psychoanalysis with psychotics without
specifying which psychoanalysis one is talking about, and without taking into
account the theoretical and clinical advances which have allowed for results
that biological psychiatry was never able to obtain with this same clientele.
Translated from original French by Michael Stanish
314
Cantin, L. (2009) ‘An Effective Treatment of Psychosis with Psychoanalysis in Québec
City, since 1982’, Annual Review of Critical Psychology, 7, pp. 286-319
http://www.discourseunit.com/arcp/7.htm
BIBLIOGRAPHY
APOLLON, W., Psychoses : l’offre de l’analyste », Collection Le Savoir
analytique, Éditions du Gifric, 1999, Québec
APOLLON, W., « Qui a peur de la psychanalyse ? », in Où va la psychiatrie ?,
Débat en santé mentale, Revue Santé Mentale au Québec, Volume XXX,
Numéro 1, Montréal, Printemps 2005, p. 165-182
APOLLON, W., « The Untreatable» in Umbr(a), a Journal of the Unconscious,
“Uncurable”, 2006, p.23-39
APOLLON, W.,« Theory and Practice in the Psychoanalytic Treatment of
Psychosis », Lacan and the Subject of Language, Routledge, New York, NY,
1991.
APOLLON, Willy, BERGERON, D., CANTIN, L., Traiter la psychose, Éditions du
Gifric, Collection « Nœud », Québec, 1991.
APOLLON, Willy, BERGERON, D., CANTIN, L., « La cure analytique dans le
traitement des psychoses », Clinique différentielle des psychoses, « Fondation du
Champ Freudien-Bibliothèque Analytica », Navarin Éditeur, Paris, 1988 : 325330.
APOLLON, Willy, BERGERON, D., CANTIN, L., « Le traitement de la psychose », in
Mental / Revue internationale de santé mentale et psychanalyse appliquée,
Edité par l’Ecole Européenne de psychanalyse, No.2, Mars 1996, Paris, p.3150.
APOLLON, Willy, BERGERON, D., CANTIN, L., “The Treatment of psychosis”, in The
Subject of Lacan, a Lacanian Reader for psychologists”, Edited by Kareen Ror
Malone and Stephen R. Friedlander, SUNY Press, New York, 2000, p. 209-227.
APOLLON, Willy, BERGERON, D., CANTIN, L., After Lacan-Clinical Practice and the
Subject of the Unconscious, Edited and with an Introduction by Robert Hughes
and Kareen Ror Malone, State University of New-York Press (SUNY), New-York,
2002.
APOLLON, Willy, BERGERON, D., CANTIN, L., « Il trattamento della psicosis », in
Il Cormorano, Centro Ricerche Scienze Umane, Almanacco Trimestrale Anno
II, no3, Mese di aprile 2003, p.14-35
APOLLON, Willy, BERGERON, D., CANTIN, L., « Les enjeux de la psychiatrie
actuelle », in Où va la psychiatrie ?, Débat en santé mentale, Revue Santé
315
Cantin, L. (2009) ‘An Effective Treatment of Psychosis with Psychoanalysis in Québec
City, since 1982’, Annual Review of Critical Psychology, 7, pp. 286-319
http://www.discourseunit.com/arcp/7.htm
Mentale au Québec, Volume XXX, Numéro 1, Montréal, Printemps 2005, p. 1727.
APOLLON, Willy, BERGERON, D., CANTIN, L., La cure psychanalytique du
psychotique : Enjeux et stratégies, Collection Noeud, Editions du GIFRIC,
Québec, Mai 2008, 374p.
BERGERON, D., « Utopia & Psychosis. The Quest for the Transcendental »,
Umbr(a), A Journal of the Unconscious, Center for the Study of Psychosis &
Culture, SUNY/Buffalo, vol. 1, 2008 : 13-35.
BERGERON, D., « Les enjeux de la psychiatrie actuelle et son avenir. Pour une
psychiatrie clinique éthique », in Où va la psychiatrie ?, Débat en santé
mentale, Revue Santé Mentale au Québec, Volume XXX, Numéro 1, Montréal,
Printemps 2005, p. 197-214
BERGERON, D., « Un parti pris pour la psychanalyse », Rencontre avec des
pionnières en santé mentale, sous la direction de Yves Lecomte, Actes du
colloque « Rencontre avec des pionnières en santé mentale les 9 et 10 octobre
2003 », édition conjointe de la Télé Université et de la Revue Santé mentale au
Québec, 2005 : 41-69.
CANTIN, L., « Préface, in “Psychoses : l’offre de l’analyste », Collection Le Savoir
analytique, Éditions du Gifric, octobre 1999, Québec, p.11-14.
CANTIN, L., « L’uomo che voleva sradicare la pulsione di morte : un caso
clinico », in Revue Setting-Quadermi dell ‘Associazione di Studi Psicoanalitici,
Sommario n. 17, Franco Angeli, Milan, 2004, p. 149-165.
CANTIN, L., « Comment rendre compte des productions de l’esprit humain, de la
psychose aux mystiques ? », in Rencontre avec des pionnières en santé mentale,
sous la direction de monsieur Yves Lecomte, Actes du Colloque « Rencontre
avec des pionnières en santé mentale », Édition conjointe de la Télé-Université
et de la Revue Santé Mentale au Québec, Collection Hors Série de Santé
Mentale au Québec, Montréal, 2004, p.71-94.
CANTIN, L., « L’évaluation "objective" des traitements en santé mentale ou quand
la recherche clinique est réduite à la méthode expérimentale », in Où va la
psychiatrie ?, Débat en santé mentale, Revue Santé Mentale au Québec,
Volume XXX, Numéro 1, Montréal, Printemps 2005, p. 183-196.
CANTIN, L., « Pour une évaluation du traitement psychanalytique
psychoses », in Revue Ruissellement, Montréal, septembre 2006, p. 39-62
316
des
Cantin, L. (2009) ‘An Effective Treatment of Psychosis with Psychoanalysis in Québec
City, since 1982’, Annual Review of Critical Psychology, 7, pp. 286-319
http://www.discourseunit.com/arcp/7.htm
CHADWICK, P., BIRCHWOOD, M., TROWER,P., Thérapie cognitive des troubles
psychotiques, traduction de Cognitive Threrapy for Delusions, Voices and
Paranoia, traduction de Chassé,F., Pilon,W., Morency,P., Decarie Edition, 2003
CORBIERE, M., « Le point sur la situation socioprofessionnelle des personnes
atteintes de schizophrénie et autres troubles mentaux graves », in Revue
québécoise de psychologie, A propos de la schizophrénie, Volume 29, numéro 1,
2008, p.95-110
CURRY, S., Commentary on the strategy and value of neuroleptic medication
monitoring, Journal of Clinical Psychopharmacology, 5, 263-267, 1985
DENIS, J.F., MORISSETTE,R., GAGNON, P., Evaluation clinico-administrative du
388 St-Vallier, Rapport des experts nommés par le Ministère de la santé du
Québec, Juin 2002
FREUD, S. « Névrose et psychose » in Névrose, psychose et perversion, PUF,
1981, p.283-286
FREUD, S. « La perte de la réalité dans la névrose et la psychose» in Névrose,
psychose et perversion, PUF, 1981, p.299-303
GENDRON,C., BUSSIERES, S., JOYAL, C.C., « Neuropsychologie et schizophrénie :
une mise à jour des connaissances », in Revue québécoise de psychologie, A
propos de la schizophrénie, Volume 29, numéro 1, 2008, p.37-49
HUGUES, R. and ROR MALONE, K., « Introduction. The Dialectic of Theory and
Clinic », After Lacan / Clinical Practice and the subject of the Unconscious, State
University of New-York Press (SUNY), New-York, September 2002 : 1-34.
KRACKE, W., VILLELA, L., « Between Desire and Culture: Conversations Between
Psychoanalysis and Anthropology », Culture, Subject, Psyche. Dialogues in
Psychoanalysis and Anthropology, edited by Anthony Molino, Whur Publishers,
London and Philadelphia, 2004 : 175-209.
LACAN, J., « D’une question préliminaire à tout traitement possible de la
psychose », in Ecrits, Paris, Seuil, 1966, p.531-583.
LACAN, J., « La signification du phallus », in Ecrits, Paris, Seuil, 1966, p.685695.
LACAN, J., Les Psychoses, Le Séminaire, livre III, Paris, Seuil, 1981.
LECOMTE, T., LECLERC, C., « La thérapie cognitive comportementale pour la
psychose- Description, efficacité et rôle du psychologue québécois », in Revue
317
Cantin, L. (2009) ‘An Effective Treatment of Psychosis with Psychoanalysis in Québec
City, since 1982’, Annual Review of Critical Psychology, 7, pp. 286-319
http://www.discourseunit.com/arcp/7.htm
québécoise de psychologie, A propos de la schizophrénie, Volume 29, numéro 1,
2008, p.63-76
MASCHIETTO, Simone, « La Psicosis e la Posizione Ética della Psicoanalisis.
L’esperienza clinica del Centro Psicoanalitico 388 in Quebec per il trattamento
di giovani adulti psicotici », Revue Setting-Quadermi dell’Associazione di Studi
Psicoanalitici, Sommario no 17, Franco Angeli, Milan, 2004.
PELLETIER, M., LUCK, D., HARVEY, P.-O., LEPAGE, M., « Apports de la neuroimagerie fonctionnelle dans la physiopathologie des symptômes positifs de la
schizophrénie », in Revue québécoise de psychologie, A propos de la
schizophrénie, Volume 29, numéro 1, 2008, p.25-36
PROVENCHER, M.D., GUAY, S., « Les données probantes sur l’efficacité des
traitements psychothérapeutiques: peut-on s’y fier? », in Psychologie Québec,
janvier 2007, p.22-24
REMINGTON, G., ADAMS, M., Depot neuroleptics in Anctil, R., Holliday, S.,
Hingenbotham, J. eds., Schizophrenia: Exploring the spectrum of Psychosis,
New-York, Wiley, 51-71, 1994schizophrenia
ROY, M.-A., ROULEAU, N., LEFEBVRE, A.-A. et al. « Génétique de la schizophrénie
et des psychoses apparentées » in Revue québécoise de psychologie, A propos
de la schizophrénie, Volume 29, numéro 1, 2008, p.9-23
Santé Mentale au Québec, Schizophrénie, délires et thérapie cognitive,
Volume XXIV, Numéro 1, printemps1999
STIP, E., GERME, F., RAGONNET, L., « Psychopharmacologie de la schizophrénie :
au-delà de l’avenir d’une illusion », in Revue québécoise de psychologie, A
propos de la schizophrénie, Volume 29, numéro 1, 2008, p.111-127
TURK, C., “After Lacan : Clinical Practice and The Subject of the Unconscious,
by Willy Apollon, Danielle Bergeron, and Lucie Cantin”, New York: State
University of New York Press, 2002, 192 pages », Psychologist-Psychoanalyst,
Official Publication of Division 39 of the American Psychological Association,
Volume XXIV, No 1, Winter 2004 : 46-48.
TURK, C., “Cultivating Lacan’s Garden in Quebec. Book Review of After Lacan :
Clinical Practice and The Subject of the Unconscious, by Willy Apollon, Danielle
Bergeron, and Lucie Cantin, New York: State University of New York Press,
2002, 192 pages”, ISPS-US Newsletter (United States Chapter of the International
Society for the Psychological treatments of the Schizophrenias and other
psychoses), Summer 2004 : 17-18.
318
Cantin, L. (2009) ‘An Effective Treatment of Psychosis with Psychoanalysis in Québec
City, since 1982’, Annual Review of Critical Psychology, 7, pp. 286-319
http://www.discourseunit.com/arcp/7.htm
VILLENEUVE, M., OLIVIER, D., « L’intervention précoce auprès des personnes
présentant un premier épisode psychotique », in Revue québécoise de
psychologie, A propos de la schizophrénie, Volume 29, numéro 1, 2008, p.51-62
COLLECTIF, Écrire à la folie, (sous la direction de Jacques Garneau), Collection
« Nœud », Éditions du GIFRIC, Québec, 1989.
COLLECTIF, La page de l'Autre. Les ateliers d’art du « 388 », Collection « Nœud »,
Éditions du GIFRIC, Québec, 2008.
Biographic Details :
Lucie Cantin is a psychoanalyst and psychologist; Co-Founder of the
Psychoanalytic Treatment Centre for Psychotic Adults where she has had a
practice as a psychoanalyst since 1982; Supervising analyst and Co-Director of
training at Gifric; Clinical Professor at the School of Psychology, Laval
University; Vice-President of Gifric; Responsible for the Orientation Council of
The Freudian School of Quebec.
Email: lcantin@sympatico.ca
319