Psychoanalysis and Psychiatry

Partners and Competitors in the Mental Health Field

Cláudio Laks Eizirik, Giovanni Foresti, Cláudio Laks Eizirik, Giovanni Foresti

• Publisher: Routledge
• Year: 2018
• eBook ISBN: 9780429823756
• Topic: Medicine
• Subtopic: Psychiatry & Mental Health

Psychoanalysis and Psychiatry: Partners and Competitors in the Mental Health Field offers a comprehensive overview of the many links between the two fields. There have long been connections between the two professions, but this is the first time the many points of contact have been set out clearly for practitioners from both fields.

Covering social and cultural factors, clinical practice, including diagnosis and treatment, and looking at teaching and continuing professional development, this book features contributions and exchange of ideas from an international group of clinicians from across both professions.

Psychoanalysis and Psychiatry: Partners and Competitors in the Mental Health Field will appeal to all practicing psychoanalysts and psychiatrists and anyone wanting to draw on the best of both fields in their theoretical understanding and clinical practice.

Part I
The Mental Health field

Global trends and local specificities

Chapter One
Psychoanalysis, psychiatry and the new frontiers of contemporary mental distress and its treatment

Antonio Andreoli

Introduction: the changing scene of contemporary mental health and its urgent need for a closer relationship of psychoanalysis and psychiatry

The changing scene of contemporary mental health provides a great opportunity to revive the controversial relationship of psychoanalysis and psychiatry.

After a wide research effort indicated that psychodynamic psychotherapy is a valuable treatment choice (Fonagy et al., 2005), evidence is growing that innovative treatment based on psychoanalytic models shows significant clinical and economic advantage, compared to various control conditions, among borderline patients (Binks et al., 2006; Stoffers et al., 2012) and other diagnostic categories with exquisite relevance to efficient care delivery and better mental health policies (Leichsenring & Leibing, 2007). Additional need for a closer relationship of psychoanalysis and psychiatry stems from psychiatric services taking little advantage of the otherwise marked progress of clinical research and management strategies as well as from the unforeseen loss of motivation among caregivers. These problems call for careful reconsideration of the legacy of institutional psychotherapy (Racamier et al., 1970; Oury, 2003; Ferruta et al., 2012) and a new alliance of humanistic values and scientific concern. Over the last years, psychiatry has endorsed a new medical paradigm praising technology transference from clinical research and efficient management via a standardized decision process and service specialization grounded on population studies and randomized clinical trials. The main limitation of the experiment was a surprising disregard of the invaluable contribution of the quality of human relationship to efficient operating services. When managers came speaking the language of academic research and business schools, the capital of institutional commitment and psychotherapeutic culture gathered over a century of institutional psychotherapy was rapidly wasted. Together with the realm of a defective model of mental disorders, a way was opened to the return of those social biases, conventional mentalities and cultural prejudices threatening the empathy of every medical milieu confronting the mentally ill. No surprise, these drawbacks had devastating effects on quality of care becoming a serious obstacle to the valuable scientific intent of the entire project. Specialized treatment is indeed just an ultimate step of a service system machine requiring compassionate dedication to such a complex achievement. A third important factor calling for a closer relationship of psychoanalysis and psychiatry is the outstanding progress of both neuroscience and artificial intelligence leading to increased attention to the mind–brain frontier (Magistretti & Ansermet, 2004; Kandel, 2005; Edelman, 2006; Damasio, 2010). Together with the rapid move of the health system into an interdisciplinary framework, the enigma of the human prompts the revival of an integrative paradigm of medical illness and its treatment. It is of note that Freud showed extreme concern for this issue claiming in his late works that psychoanalysis endorses the Weltanschaung of science being threatened on one side by reduction to experimental psychology and on the other side by an elective drift into philosophical speculation and magic belief (Freud, 1932). It is of note, however, that while psychoanalysts are more aware of the several issues discussed above, yet psychoanalysis and psychiatry are increasingly being set apart, especially in the academic and institutional fields. Such an opposite move is even more alarming considering the simultaneous divorce of Subject and science in modernity culture (Touraine, 1992). To discuss this problem, this work will investigate the present irresistible rise of a new acute psychiatric patient. A prominent figure of the changing scene of contemporary psychiatry, the emotional crisis of these subjects has grown into an epidemic accounting for an overwhelming majority of psychiatric populations. The peak of the iceberg of a more widespread malaise, the vicissitudes of these patients highlight a new frontier of contemporary mental health and its clinical, institutional, cultural and epistemological relevance to the revived dialogue of psychoanalysis and psychiatry. This work is intended to study this intriguing issue using studies from others, data from clinical and service research conducted in Geneva and my own psychoanalytic works.

A new epidemic and its relevance to treatment innovation and better care delivery

Over the last several years, both the absolute number and the relative proportion of patients referred to acute psychiatric treatment has showed a tremendous rise. The trend started insidiously after World War II and became extremely widespread during the de-institutionalization era. Thereafter, this phenomenon led to relentless pressure on emergency rooms, psychiatric hospitals and outpatient centers. This epidemic was associated with a new diagnostic profile of the patient population almost consecutive with the surge of a new figure for acute psychiatric patients. Those schizophrenic, bipolar and mentally deficient subjects accounting, a few decades ago, for the overwhelming majority of hospital admissions were rapidly outnumbered by a newcomer exhibiting some combination of maladaptive reaction to adverse events and structured psychiatric illness triggered by various social and medical problems. Impulsive and unstable, meeting diagnostic criteria for several diagnostic prototypes of the affective spectrum and personality pathology, abusing psychoactive substances, scoring high on suicidal risk scales, and often triggered by various social problems and somatic illness, these subjects are confronting both psychiatric services and private practice with dramatic clinical and ethical dilemmas. Their acute distress, severe risks and insidious long-term outcomes are indeed of serious concern since their problems do not respond well to the usual treatment. Too severe to be managed in an outpatient setting, not improving, or even worsening, where hospitalized, the new acute psychiatric patient accounts for an enormous consumption of useless, costly services with little benefit in a mental health system doing much but not taking care of his/her real needs.

Innovating acute treatment: a call for psychoanalytically inspired clinical research

The most intriguing issue among these patients is the valuable containment of upsetting anxiety and chaotic mental functioning resulting in an exquisite mix of loss of emotional control, interpersonal conflicts, disordered behavior and helplessness. Together with personality disorder and a social profile facilitating rejection by close family, friends and caregivers (Andreoli et al., 1989), this factor accounts for a large proportion of the short-term and long-term outcome in these populations (ibidem). Equally important, psychotherapeutic intervention, and a system of service likely to provide it in adequate format, are the only treatment factors showing significant positive interaction with the outcome of these patients. Here we meet the clinical research problem calling for a closer relationship of psychoanalysis and psychiatry. The emotional crisis of the new acute psychiatric patient is strikingly similar to those storming episodes every psychoanalyst is used to going through with his/her patient in the psychoanalytic office. On both sides, an upsetting experience stems from a breach in the mentalization processes leading to a disorganized style of interaction and communication, maladaptive emotional reactions and cognitive distortions in a useless effort to gain some control (Bateman & Fonagy, 2004). Raising serious limitations to the psychoanalytic process and classic transference working through, this psychopathological enigma, and its relationship to compulsive repetition, have attracted enormous interest among psychoanalysts from pioneering works (Fenichel, 1945) to recent controversies (Green, 1997), plunging the psychoanalytic movement into an exciting debate (Foresti, 2013) and a number of endless inconclusive conflicts as well (Haynal, 1988). Considerable progress has come in the field from empirical investigations of impaired mentalization process and its root in attachment disorder as well as from empirical evidence of a significant association of attachment disorder, impaired mentalization and Borderline Personality Disorder (Fonagy et al., 2002; Mayes et al., 2007). Thriving on purely psychoanalytical material, A. Green (1997) has conceptualized the field as a “Clinique du reel” (see below)in contrast to a “repression related clinical field.” The concept of “reel,” derived from Lacan (1975), encompasses “what lies beyond the symbolic texture linking meaning, symptoms and repression,” confronting the subject to the Freudian “Unerkannt,” i.e. what cannot be told or written (for further discussion see: De Mijolla, 2002). The surge of the “Clinique du reel” would fall, according to Green, under sudden failure of the double barrier of watching the sensorial evidence of external reality and traumatic intrusion from the Es. The new acute psychiatric patient construct is primarily intended to extend the field to question the following issue: how much recent progress of psychoanalytic savoir and psychodynamic research is relevant to the real acute patient of general psychiatric services as well as to the clinical and institutional issues associated with its effective treatment? Classic psychoanalytic treatment, both on the coach and in a face to face setting, is feasible and useful among gifted, sensitive and socially privileged acute psychiatric patients with less impulsivity, paranoid reaction and a decreased load of additional axis I and/or axis II pathology. Yet, psychoanalytic treatment still requires among these subjects enormous flexibility, especially within acute emotional crises, and is hardly ever terminated. A larger subgroup of new acute psychiatric patients meets diagnostic criteria for Borderline Personality Disorder (APA, 2000), a prototype with special relevance to clinical research. A new generation of clinical trials (Bateman & Fonagy, 1999, 2008, 2009; Clarkin et al., 2007; Doering et al., 2010) has indicated that specialized psychodynamic psychotherapy based on various psychoanalytic models of disordered mental functioning is cost-effective among these patients. These works have provided a first demonstration that careful translation of psychoanalytic observations into testable research hypotheses is of significant medical and economic concern and may contribute to considerable advances in a field of enormous concern. Nevertheless, the Borderline Personality Disorder prototype accounts for a minority of new acute psychiatric patients and the practical impact of specialized psychotherapy in ordinary clinical environments is questionable. A very large majority of acute psychiatric patients belongs to a much wider and heterogeneous clinical field. Meeting more often severity than duration criteria for Borderline Personality Disorder, showing polymorphous co-morbidity and psychosocial profiles, these individuals are the enormous reservoir of a new psychotherapy need, both in terms of psychotherapeutic service culture and structured outpatient psychotherapy. Beyond impaired mentalization and traumatic anxiety, rupture, loss, separation and sudden discontinuity of human bonds are equally distinctive features of the syndrome. An issue widely investigated by previous psychodynamic studies (Horovitz et al., 1984), the pathological mourning process is at the forefront of the clinical evolution of these patients and a main therapeutic issue to which we have to respond to put an end to the emotional crisis accompanying psychiatric disorder among these persons. Simultaneously, their pain and despair tells psychiatrists and psychoanalysts about the insidious ability of disappointed love (Hill at al., 2011) to open the door of the “Clinique du reel,” destabilizing the complex system of fantasies, identifications and inner object relationships inhabiting the underground of their Ideal. Recent studies from our group (Burnand et al., 2002; Berrino et al., 2011; Andreoli et al., 2016) have shown the importance of paying more attention to this problem and its significant relevance to cost-effective crisis intervention at general hospital and outpatient psychotherapy. Various forms of specialized interventions focusing on disappointed love have shown thereafter superior efficacy and economic advantage compared to the usual good quality intensive treatment among unselected real patients with depression and/or severe personality disorders, a diagnostic subgroup accounting for a wide majority of the new acute psychiatric patient population (ibidem). Also important, psychoanalytically inspired acute treatment focusing on disappointed love has been found well adapted to provide a cost-effective intervention with equal impact either delivered from trained psychotherapists of from gifted caregivers with little psychotherapy training (ibidem).

Translating the legacy of institutional psychotherapy into contemporary service culture

Beyond medical and economic concern for individual treatment and specialized psychotherapy, the surge of such a new patient population calls for a renovated structure and enhanced operating efficiency of the mental health system as well as for a new service culture. Valuable provision of cost-effective acute care requires, indeed, an exquisite mix of empirical stand, compassionate dedication, inter-subjective skill and an aptitude for interdisciplinary work. Here is a second issue with special relevance to a closer relationship of psychoanalysis and psychiatry: the present call of the contemporary scene of mental health for an alliance of institutional psychotherapy and scientific medicine. While extreme mutual disregard has resulted, over the past years, in a war between evidence based medicine and institutional psychotherapy, the two respective paradigms call for some form of alliance. Nothing but an evidence-based medicine framework demonstrates that psychoanalysis easily becomes, especially in psychiatry, defensive against anxiety and purely speculative beliefs, facilitating avoidance, chaotic decision and final drift into the magic stance of popular medicine. Simultaneously nothing but an evidence-based service operating framework shows the permanent drift of doctors and caregivers who apparently endorse this model towards an erratic, unreliable decision process while confronted with a stressful encounter with an acute mental patient. Cutting across scientific medicine and dynamic psychiatry this trend highlights how both disciplines want to get rid of a companion they desperately need. Here we get to the important point of this paragraph. This is in keeping with paying simultaneous attention to service innovation, treatment research, training and supervision to develop a new psychiatric culture that enhances the dialogue of science and psychoanalytic savoir among caregivers. The first intent of this project should be reviving those political and humanistic values prompted by the institutional psychotherapy movement, inventing them in a new key more adapted to confronting the changing scene of contemporary psychiatry. Access and reaching out, structured assessment and a valuable decision process, service efficiency and staff cohesion go with a moral factor accounting for the quality of human relationships, careful recognition of the unique experience of a given patient and a curiosity with the virtual world of what goes on in the everyday interaction with his/her family and friends and the everyday walkabout of a psychiatric service. An important efficiency and effectiveness factor is, therefore, to resist the constant trend of simultaneously kicking out evidence-based guidelines and the human of the human of the acute disorder. The encounter...

Table of contents

• Cover
• Half Title
• Series Page
• Title
• Copyright
• Contents
• SERIES EDITOR'S FOREWORD
• FOREWORD
• FOREWORD
• ACKNOWLEDGMENTS
• LIST OF CONTRIBUTORS
• Introduction
• PART I The Mental Health field: global trends and local specificities
• PART II The clinical practice: nosology, diagnoses and treatments
• PART III The formative dimension: teaching and continual education
• INDEX