Psychothérapie et phénomènes de langage : une application clinique de la phénoménologie

The question is what possible interaction can be found between a personal interest in phenomenological philosophy and the practice of psychotherapy? To begin, applying a phenomenological thought process enables one to point out the distinction between the symptoms, rooted in reasoning by inference, a by-product of somatic medicine, and the phenomenon, as sensed by the psychiatrist, often without actual recognition. The intuitive grasp of phenomena requires the qualification of a sustained distancing as regards any established knowledge, which puts one in the position of being surprised by events, just as you can let yourself be surprised by children. In this way, it can be illuminating to compare the “sense of realisation” experienced through the psychotherapeutic dialogue with the account of a dream such as a child may supply. This is the kind of discourse which may witness the birth of “meaning in the making”, lack completion, which differs from the intentional meaning of acts of consciousness, such as traditionally described in phenomenology. In its manifestations, this meaning can be related to artistic significances, and particularly those, which are displayed, live during of an improvisation. Finally, applying a phenomenological method makes it possible to reveal as a true moment of crisis the moment when the continuity of discourse is interrupted, for example when experiencing boredom during an exchange. Such an interruption brings to light a fundamental feature of time and affectivity.     

La démarche originale de Gisela Pankow

The author exposes conceptual basis of Gisela Pankow concerning therapeutic view of psychosis and other psychical disorganisation forms. E. Kretschmer teaching, whom she has been the disciple and the collaborator at Tubingen, as well as phenomenology, are - amongst others - unavoidable sources to understand her “Body Image” concept and also her process of symbolisation in a synthetic purpose of the theory of the sign and access to language. The “body-image” is much more a dynamic organisation than a specular picture which is only its projection into space. The access to language and the genesis of the sign are to be thought in a already-lived and already-felt body to allow access to the other and thus a possibility of symbolisation.     

Plaidoyer pour les cothérapies non-intégratives

The official way of taking care of the mentally disabled is by its principles, procedures and techniques a two-fold treatment. It will appear in this paper that our preference goes to the most traditional of the two options, the combined-therapies, in other words the “multisided therapies”, also called the “focus-shifting” strategies. The issue concerning combined therapies with two or three focuses being applied to severely disabeled patients is raised. This involves simultaneously an analytic investigation as well as behavioral psychotherapy, together with medication and support. Concerning the other more popular technique - the “integrating psychotherapies” - also known as the “psychotherapeutic movement for integration”, it will be critically examined. Our aim is to show that this integrative approach in psychotherapy is an offshoot from the eclectic and pragmatic american school of thought.It is not compatible with a psychoanlytical approach even when it tries to use its clinical and theoretical contribution.     

Évaluation de l’intelligence sociale chez l’enfant présentant des troubles spécifiques du langage oral : Présentation d’une échelle d’évaluation clinique

Performances in social abilities of everyday life were studied in children with specific language impairment or PDD (pervasive developmental disorders). Comparison was made with normal children, children with intellectual deficiencies and dyslexic children. Results concerning children with language impairment confirm a relationship exists between language abilities and social cognition abilities, development of theory of mind being likely to go along with the development of language. The second objective is to establish normative values for the EASE scale. Hence, 327 normal children of various ages were tested. Results show a significant effect of age on mentalization development and results confirm that this ability is acquired between three and five years old. Normative values have been thus established. This study may allow to propose the EASE scale as a tool to help diagnosis, in particular to help make differential diagnosis of pathologies leading to troubles of language and personality in young children, such as “PDD” (atypic autism among others) and “SLI”, as well as to have clinical tools which enable to make a diagnosis in younger children. The EASE scale therefore presents greatest importance.     

La gestion des affects dans la relation thérapeutique chez le patient schizophrène

This article studies schizophrenic patient's affective conflict by non-integrated ambivalence and absence of symbolisation of affect. Through the meet with a psychotic patient, the authors show that evolution of therapeutic relation is on a par with affect-representation link and its expression in therapy. The authors differentiate processes, which are involved in affect-representation link ; ones concern on representation (in particular déscénarisation and démétaphorisation), others concern on affect, as “thinging” of affects and external deposit of affect. The term of “insulating split”, a form of psychotic insulation, is used to describe this process.     

Bilan d’années d’art-thérapie

Our experience of twenty years in art-therapy confirms its great difficulty, if its aim may be a true psychotherapy.     

Les capacités d'élaboration : concept transdimensionnel

In everyday clinical practice, the term “ability of elaboration”, an empirical concept, is supposed to assess the mind's construction and structure. In psychiatric literature, terms with similar meaning exist, but they are not clearly defined. Does ability of elaboration have a conceptual strength? If so, is it a trans-dimensional concept? The empirical state of this concept frequently used at the end of a psychiatric examination justifies language, the translation of the patient's symbolic activity, to be considered as the beginning of our reflection. Subjects use symbolization to attribute subjective meanings to traumatic or non-traumatic events, language being the usual way of expression of this symbolization. It could result from the patient's ability to adapt. It would vary because of structural and contextual factors as affective maturation or emotional, psychological and physiological contexts. The way symbolization is processed can be modelled in different ways according to main psychiatric currents. Considering psychoanalysis theories, symbolization would result of complex mechanisms (meaning, coherence, psychic development). Psychic development links signifier to signified, restores symbolic activity, its main expression being language. Language gives the subject the possibility to transmit his psychic work. In clinical practice, psychic elaboration is predominant because trauma is intrinsically meaningless and cannot be spontaneously symbolized. Defence mechanisms could operate to make this trauma meaningful. The ability to put words on traumas would be a consequence of the ability of elaboration. But the ability would be insufficient or absent if language did not permit intelligibility. There would then be other ways to express elaboration: psychosomatic or behavioural signs. Ability of elaboration should be considered as the result of dynamic and protean tools. These tools would be necessary to resolve internal or external psychic conflicts. They would help to constantly adapt the subject to his environment. This would justify their importance in clinical assessment for diagnosis and prognosis. Ability of elaboration, empirically used, may finally be a trans-dimensional concept.     

Troubles des habiletés manuelles et impact sur la vie scolaire : création d’un test de manipulation des outils scolaires : le Man.OS

Objective

The assessment of manual abilities in children is carried out in occupational therapy through the observation of fine motor skills without an object (repetitive and sequential tapping) and with an object (prehension, reaching). There was a lack of an assessment tool of the manual abilities with objects of everyday life for children older than 6 years old. The Man.OS was developed; a manipulation test of “stationary” tools such as erasers, rulers, scissors, etc associated to an analysis of this activity, dissociating the procedural components of the manipulation and the quality of the production itself.

Method

One hundred and twenty children from grades CE1, CE2 and CM1 from Parisian schools were asked to display their skills on these manipulations.

Results

In general, good manual abilities were observed with percentages of success always superior to 50%. Specific results for each tool are also given.

Discussion

Further studies should include more items, older children and from other regions.     

Medulloblastomas: review

Introduction

The term of “medulloblastoma” refers to cerebellar tumors belonging to the family of primitive neuro-ectodermic tumors (PNET). Medulloblastomas represent 40% of cerebellar tumors, 15 to 20% of brain tumors and the first cause of malignant brain tumors in childhood. Seventy to 80% of cases are diagnosed in children versus 20 to 30% in adults.

Updated knowledge

Diagnosis is based on clinical and radiological exams, and proved on pathological analysis in association with molecular biology. Treatment comprises surgery, craniospinal radiotherapy except for children under five years of age and chemotherapy according to age and high-risk criteria. Medulloblastoma is a rare case of a central nervous system tumor which is radio- and chemo-sensitive. Treatment goals are, on one hand, to improve the survival rates and, on the other hand, to avoid late neurocognitive, neuroendocrine and orthopedic side effects related to radiation therapy, notably in children. The prognosis is relatively good, with a five year survival rate over 75% after complete resection of a localized tumor although sequelae may still compromize outcome.

Perspectives and conclusion

Management of patients with medulloblastoma implies a multidisciplinary approach combining the contributions of neurosurgery, neuroradiology, pediatric oncology, neuro-oncology and radiotherapy teams.     

Travail psychanalytique, transfert et maniement du transfert dans la cure des personnes diagnostiquées « psychose » ou « schizophrénie »

The possibility of a psychoanalytic treatment or cure in the case of a psychotic patient is the controversial subject of many discussions. We are reminding in this paper Freud's different positions about this subject, in order to show his ambivalence. We examine further the hypotheses and techniques that are proposed by several schools of psychoanalysis and we show how the technical rules of the treatment are resulting mainly of theses hypotheses concerning the etiology and the pathology. The technical rules are inducing a particular position of the analyst, which is different for each school. We assume that these postures are not excluding each other, but they are reflecting particular “moments” of the treatment, or specific “techniques” which are more or less appropriated for each category, we explicit different postures and we match they with these proposed by Freudian, Lacanian or Kleinian authors. The imaginary transference is the one described by Freud in “An Outline of Psychoanalysis”. It represents the transfer on the analyst's person of an early significant figure (imago). We argue the idea that the initial transference of a psychotic person is a transfer of “functions”, as in the R-scheme described by Lacan. The symbolic transference involves the language, i.e. the working out of a delusion. The real transference is the contrary of the neurotic process of “uncovering” the object: it is the one, which grasp the object into the discourse. We argue the idea that there is a possibility of structural mutations between psychosis and neurosis. The structure is conceived as a preferential pattern of relationship (transference) at a “m” moment.     

Les thérapies médiatisées, médiations artistiques. Musicothérapie

The music therapy is one among the four specialties of the arts therapies. It is known since ancient times and in every culture. Its professionalization is recent, in France as on the international level. This article presents a short history, basic theories, principal methods, what it is for, and how are its effects evaluated. The reader will find the debate on the place given to art in the therapies, and precisions on the new trainings (Master degree professional and research).     

Les thérapies utilisant la réalité virtuelle dans les troubles phobiques

For the past 15 years, virtual reality has been increasingly used as a therapeutic tool in psychiatry. In particular, virtual reality exposure therapy (VRET) has been developed from and proposed as an alternative to standard cognitive behavioural therapy (CBT) for the treatment of phobic disorders. Using real-time computer graphics and visual displays, the patient is immersed in different computer-generated virtual environments specifically designed for different types of phobia. As imaginative or in vivo exposure therapy, VRET consists in a gradual presentation of phobic stimuli. The desensitization through VRET has been found to be efficient in different types of anxiety disorder, and in particular in phobic disorders. Moreover, it presents most of the advantages of both in vivo and imaginative exposure therapies without most of the inconveniences. Indeed, VRET can be tailored to individual progression. It takes place in the privacy of the therapist's office, ruling out all the problems of confidentiality. It can be repeated or prolonged easily, even for rare or dangerous situations. It is less time-consuming for the therapist and really more acceptable by the patients. This report presents the preliminary results of a controlled and randomised study suggesting a comparable efficacy of VRET and standard CBT for the treatment of panic disorder with agoraphobia. Moreover, new therapeutic targets are investigated, like fear of falling. As a conclusion, VRET represents an interesting alternative therapeutic method to standard CBT for the treatment of phobic disorders, but it is generally not sufficient and has to be included in a more global therapeutic project.     

Psychoéducation et attitude phénoménologique en psychothérapie de groupe

Objectives

Psychoeducation contains the risk of a misunderstanding in the effective experiences of recognition. We want to show that group psychotherapy can be a means to reconcile recommendations in disease prevention aimed by psychoeducative measures, the vivid and lively dimension of experience found in phenomenological attitudes and aspects, turned to the community world of therapeutic mediation.

Method

To articulate these various domains, we approach the principles of psychoeducation, the risks which this one can contain and the contributions of clinical phenomenology. Phenomenological method is different from what we call collectively clinical intuition which is always implicitly colored by the typical contexts of meanings of what appears (meanings which have a practical and effective reach for example) and stay, in spite of the critical distance which we can put it, stuffed with various emotional and theoretical predicates muddled between them. The phenomenological attitude aims as much as possible to a suspension of these predicates, that these predicates arise from the common sense of everyday life or that they arise from a detailed specialized knowledge, and this to remove the “coats of sense” which settled on the perception.

Results

The group, by its multiple interactions, aims at an optimization of the articulation of the self-relationship with relationship socially adapted to the others. The therapist constantly has to attend to dialectical dynamics which reigns between a certain self-dissolution in the group and a return to oneself from the meshing which build up itself within the group. For certain patients, it is particularly difficult to maintain a just balance between the two moments of identity, the one which is peculiar to oneself and the one which emanates from relations with the others towards which we are normally constantly turned. The interest of this psychotherapeutic work in group is here to offer to each of participants the possibility of holding, with a little more confindence, an existential position within a meshing of social links, that is a capacity to seize oneself as existing among the other beings having themselves an own existence. From there, the subjective capacities of each can be better recognized, what can also give place to adjustment of these capacities with individual aspirations. The active implication of patients, so looked for by psychoeducation, is all the more tangible as we were so able to appeal, by the phenomenological attitude, to what feels immediately and without distance as much in an intimate self-relation as in relationship to the others.

Conclusions

Phenomenological attitude allows not to get stuck in imaginary expert skills, in rational projects of organization and other methodical constructions of the science. This attitude is particularly interesting for group psychotherapy which privileges the opening rather than a work of elaboration. The stake is so the authenticity of a real therapeutic alliance based on fine regulations of the global situation of co-presence taking into account the interlacing of the implicit and the explicit in the exchanges which weave with the patients. We privilege a fertile step rather than rigorous observance of a method which would lead only to a systematization against the spirit of phenomenology. The clinical experience shows that this psychotherapeutic method allows in particular a regular attendance of the group, what is one of major ingredients of its efficiency.     

L'adolescent malade : quelle guérison pour le corps ?

The legitimacy of therapeutic mediations has long been asserted in care centres. Yet non verbal, body-oriented mediations appear to have retained a singular status, particularly in those psychiatric institutions concerned with the adolescent and the young adult. Traditional ergotherapy has adapted to the new mediators of the young (video games, multimedia, cinema, etc.). At the same time it has made a step in the direction of occupations which involve the physical body more explicitly - when any such association had usually been excluded from therapeutic mediations that privileged the verbal expression as the principal tool to restart the symbolisation process. We have set out to investigate the part such body-oriented mediations play, and whether they are a superior mean in dealing with patients resistant to other forms of assistance. We have concerned ourselves with the indoor climbing activities which take place in the out patient “care and study” department of the hospital (Clinique Dupré). We reason that the learning and safety aspects of indoor climbing permit to re-enact regressive phenomena associated to the repetition of early experiences of distress. Climbing as a mediation opens the therapeutic doors by allowing the physical resurrection of those early experiences which had yet to be symbolised.     

Prise en charge thérapeutique du syndrome de Gilles de la Tourette chez l’enfant et chez l’adulte

Tourette's syndrome is a neuro-psychiatric disorder which starts in childhood and is characterized by the association of motor and vocal tics of which the frequency, type and location vary in time. The numerous ways of neurotransmission of the physiopathology of this illness have been tested. Several psychiatric comorbidities have been described at length among which the attention deficit hyperactivity disorder and obsessional compulsive disorder are the most frequent. The decision to initiate a treatment must take into account numerous factors and notably the repercussions of the pathology on the social and occupational life of the patient which rest on an individual valuation of the illness. Care must first start with psychoeducation allowing a better understanding of the syndrome by the patients and their family. Medicinal therapeutics then intervenes to treat the weak to severe tics affecting the daily life of the patients. The choice of the molecule will differ according to the severity of the illness, to the age of the patient and to the comorbid associations. Psychotherapies such as behavior therapy and supportive therapy are an alternative to pharmacologic treatment. They can be employed alone and may be sufficient for some patients. They can be also associated with classic therapeutics in order to increase therapeutic effectiveness. Finally, deep cerebral stimulation may constitute a new and interesting way, but it is in its developmental stage and needs to be assessed. This treatment is restricted for the time being to cases resistant to the classical treatments and to patients meeting the requirements of eligibility for such treatment.     

La médiation de la musique en psychothérapie

The choice of music as a therapeutic mediation is justified through consideration about the human being and his musicality, and about the components of music. The concept of therapeutic mediation, referring to Winnicott’s works, may be applied with advantage to the field of Musictherapy. It leads us to characterize the specificity of the therapeutic relation, and to emphasize the complexity of techniques. We shall end with recalling the definition of Musictherapy taking into account all those elements.     

Effraction d’un cadre psychothérapique en milieu carcéral et décompensation psychotique

The objective of our study is to prevent pathological outcomes of the institutional abuse in a prison facility, which can trigger a psychotic breakdown of inmate patients, by enhancing a healthy communication between penitentiary staff and medical team despite the fact that they both adopt two opposite approach of inmates. In France, since 1994, public health institution took in charge medical and psychological penitentiary follow-up through Counseling and Ambulatory Care Units (UCSA). Composed of a multi-field team (psychiatrists, psychologists, medical staff), those care units have to constantly deal with security and normative issues specific to the prison facility. Usually, it is difficult to keep the psychotherapy setting safe from external “attacks” inflicted by penitentiary staff. Moreover, admitting UCSA within prison walls raises the eternal conflicting issue between two opposite logics: punishment (related to guilt) and treatment (related to illness and suffering). Whereas, UCSA staff perceives inmates as patients (to be cured), penitentiary staff perceives them as “cons” or out-laws (to be punished). The daily confrontation of such opposing logics not only affects the quality of communication between health team and penitentiary staff, but it also triggers acting-outs which put to the test the feasibility of psychotherapy in a prison setting mainly with mentally vulnerable inmate patients. Our method is based upon a case study of an inmate patient, C., who suffered a psychotic break down as a consequence to the unannounced renovation of the office dedicated to his psychotherapeutic sessions. Though, it is true that C., a former addict, had already a psychotic predisposition, his encounter with the intrusive and arbitrary authority of the penitentiary institution triggered his mental breakdown while undergoing psychotherapy. The result of our study emphasizes upon the necessity to establish a true communication between the medical team and the penitentiary staff and a mutual understanding of the value of their professional task in order to contain any conflict issues or misjudgment that may affect the progress of the most vulnerable inmate patients. Our study concludes to the importance of a complementary, cooperative, comprehensive and balanced approach of mental health problems in a prison facility through continuous training courses and discussions involving both penitentiary staff and medical teams whose roles, despite their differences, revolve around the same goal: the social and mental rehabilitation of inmates.     

Art-thérapie et addictions, l’exemple des troubles du comportement alimentaire

The Centre d’Étude de l’Expression at the Sainte-Anne Mental Health Hospital is a particular unit of the hospital in the university clinic. This centre is specialized in psychotherapy through art, and there are 30 workshops of art therapy per week. The techniques used are painting, modeling, music, dance, theatre and creative writing. Each workshop is conducted by a professional specialized in art therapy and has much experience in this field. The way of being admitted into the workshops of art therapy is systematic. It is the same for all the workshops. Patients with nutritional problems are often capable of verbally expressing themselves at a good level. However, for them, the use of speech is not a way of communicating, neither with themselves nor with others. No verbal and artistic psychotherapies are then very useful and specific.     

Trouble déficitaire attentionnel avec hyperactivité et trouble bipolaire. Une revue

The future of children suffering from Attention Deficit Hyperactivity Disorder (ADHD) remains discussed. This article questions about ADHD being a prodromal sign of adults'Bipolar Disorder (BD). Therefore we aim to clarify the links between these two disorders. It appears that there is an association between them. This is shown by an elevated comorbidity, a familial association, a higher risk of BD in the future of the ADHD patients. The presence of an ADHD (especially some sub-types) can be considered as a clinical predictive factor for a later BD. Moreover, BDs present some common features in this context. Finally, data from genetic familial studies suggest that the ADHD + BD association is a distinct familial sub-type and may be related to what some have termed childhood-onset BD. Thus these links raise nosological questions and may have important practical impacts.