Résilience familiale et transmission transgénérationnelle du traumatisme de la Shoah

The clinical concepts developed in the present paper concern the resilience and the trans-generational transmission among families of Holocaust survivors. In physical terms, "resilience" is defined as the ability of a material to regain its shape or original position after having been compressed or stretched. In human sciences, “resilience” is the capacity of certain individuals either to adapt successfully to adversity, or to function in a competent manner when faced with a traumatic situation. The concept of trans-generational transmission of trauma is mentioned by numerous authors in explaining certain types of psychological suffering endured by several generations of the same family, notably among descendants of Holocaust survivors. In some traumatized families, all the energy is used by a mourning process and by strategies of survival. Memory of death is everywhere and memory of life is repressed. To help those families, psychotherapists have to inverse the situation by revealing the memory of life and by limiting the role of the memory of death. We present here several clinical observations that we made during therapy sessions with certain families of Holocaust survivors. These families consulted with us because of the symptoms presented by members of the third generation (the grandchildren of the Holocaust survivors) as adolescents. These symptoms were not specific, and included various categories such as dropping out of school, behavior problems, self-mutilation, eating disorders, drug abuse, depressive or anxiety disorders, and problems with aggression. These families presented some specific patterns in their relationships, which led us to consider that the symptoms presented by the third generation might be a consequence of the family's history and the trans-generational transmission of Holocaust trauma. We also describe here the clinical strategy that we developed to assist these families. This strategy was used in addition to classical individual and linear treatment of the symptoms and consisted of an attempt to reinforce the relationships between Holocaust survivors and their grandchildren with the aim of stimulating a structuring trans-generational transmission. In effect, at the liberation of the camps, certain Holocaust survivors used, as a mechanism of individual resilience, control over their memory and their emotions. In effect, their psychological survival was impossible without making sure that their terrible memories and inexpressible feelings could not occupy their consciousness. In stifling their memories and their history, they created a void in the parenting of their children and their grandchildren. In order to fill this void and to unblock familial memory, we make use of the privileged position occupied by the grandchildren of Holocaust survivors. In effect, Holocaust survivors generally adopt a more flexible attitude toward their grandchildren than toward their children. Therefore, we entrusted them with the task of reconstructing the history of their family before and after the Holocaust through consulting their grandparents, most of all, but also other members of the family, whether it be directly or by courier (eventually electronic, in the case of geographic separation). Our therapeutic approach improves the flexibility, adaptability and communication of the family. Moreover, it improves the bond between Holocaust survivors and their grandchildren and permits the latter, through a better knowledge of their family history, to acquire a trans-generational shadow.     

Thérapies familiales et maladies mentales complexes

If complex mental diseases are affecting not only persons who present troubles, but also their close relatives, the way to proceed needs new and specific family interventions in a therapeutic purpose. Most often the demand comes from the professionals involved in the care. They have to deal with the reduction of individual and family autonomy. The first step is to delimit the fields of shared helplessness, in a way to enhance the therapeutic potentialities, which appear at the boundaries of these fields and which appeal to the life ecosystem's resources. Then the focus of the therapy is today life-axis than history, prospective rather than retrospective. The purposes are to help and hold the family members, to relieve their sufferings, to reduce their anxieties, to offer a space of humanity, of conversation, of elaboration about what happens, of emotional and cognitive sharing.     

Psychothérapies des psychoses : entre histoire et évaluation

Historically, the psychotherapy of the psychoses was bound to the psychoanalysis in the questions around the possibility of transfer at the psychotics then in the developments of the psychoanalytical technique and in the use of against transfer. The development of medicines and the formalization of the other psychotherapeutic techniques (family, cognitive and behavioural psychotherapies) advanced the necessary coordination of the care to go of an exclusive psychotherapy centred on a type of treatment towards an integrative psychotherapy. The model dominating at present notably in the USA is a psychosocial model which uses the medicinal treatment, the family psychotherapy and the psychotherapeutic techniques of type TCC. The objective of this care is to limit relapses and consequences of the negative symptoms which pull isolation. The future of the psychotherapies of the psychoses articulates the evaluative dimension to be able to define real therapeutic integrative strategies and the individual dimension where the meeting with a subject is in the heart of the therapeutic device and where the psychoanalysis keeps all its interest.     

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.     

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.     

La psychothérapie de l'enfant : la symbolisation accompagnée

The psychotherapy of children may be carried out by psychiatrists and psychologists, but also by psychomotricians, language therapists, etc. It varies according to age, pathology, context, expectancies. Symptoms, language use, introspection capacities, capacities in various domains such as language, body expression, etc. are taken into account. Treatment is indicated according to each individual situation. Psychotherapy is conceived as a method for accompanying symbolisation. It is meant to help children use playing and creativity as methods of symbolisation. It does not aim at searching unconscious significations. Art therapy may now be used in the field of social interventions or teaching, as a way to reduce the violence of contemporary society.     

Évaluation d’un nouveau format de psychothérapie de groupe émotionnel

Emotions today play a fundamental role in therapeutic treatment. We have developed a new group psychotherapy format in order to tackle the body and the spirit at the same time, as well as the constant intricacies between the two. This new format jointly tackles psychoeducation, emotional expression, emotions from different angles, metacognitions and emotion in its social expression. These preliminary results allow us to confirm the solid grounds for pursuing this type of group format.     

Prise en charge psychothérapeutique de la douleur dans la fibromyalgie. À propos d’un cas

Fibromyalgia has an historic link with the neurasthenia from the end of the 19th century. It has been recently identified as a syndrom after other names have been used such as fibrositis, polyalgic syndrom and chronic fatigue syndrom. The new criteria of the American College of Rheumatology are now including psychological symptoms as fatigue, lack of sleep, cognitive disorders. It shows that this pathology oscillates between the somatic and the psychological poles in its definition. The physiopatholgy of fibromyalgia remains uncertain and the main medical model of understanding this condition is based on the bio-psycho-social model of stress. The therapeutic strategies used for managing fibromyalgia include analgesics, antidepressants educational therapy and relaxation. We will present a case report with a therapeutic approach based on psychosomatic and psychotherapy using psychoanalytical concepts. Concepts such as retention, anger repression, splitting are used with the view of explicitating the link between physical and psychological symptoms. We can approach fibromyalgia as a tensional pathology in a broad sense. The therapeutical relationship is also explored and how it is possible to help the patient to mentalize, to deal with anxiety and painful grief which are deeply repressed. The physical pain is becoming chronic because the ego can find a way to satisfy different drives by overinvestment of the pain. The process of identification to the father is also explicated. We will see that we have to be quite flexible with the therapeutic setting, and also that the act of prescribing can be useful to the psychotherapist.     

Séquelles délirantes d’une psychose puerpérale ancienne, un climat d’inquiétante étrangeté : observation clinique

Mr and Mrs P., recently settled in the area, are experiencing difficulties. Mr P. suffering from depression has to be admitted to the hospital. Mrs P., who suffered for years from bipolar trouble, is sent to the outpatients department for medical supervision of her lithium treatment. Discussions with her and the reading of a text she wrote years before bring back a delirious experience, which happened 20 years ago involving the disturbing strangeness of a world of goats. This looking back into the past becomes the starting point of an intense pictorial productivity on which the psychotherapy will be based… An eight months effort which will succeed in obtaining the normalization of family life and a better adaptability to reality.     

Mentalisation et psychothérapie chez le patient limite

Psychotherapy of borderline patients allows us to observe that often, the intense affects, the rage and the lack of good internal objects prevent the mentalization of object relations that are confined to acting-out. Moreover, mentalization deficiency inhibits the experience of relationships with a good object in the transference, which often jeopardizes the continuation of the treatment. It is argued that these dimensions of borderline pathology can be better worked out by closely adjusting therapeutic interventions to the patient's ability to mentalise psychological experiences, particularly with regards to positive transference. We explain our view that the capacity to mentalise in the transference a relationship with a good object is an indication of structural change.     

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.     

L’épreuve d’anticipation, une étude de cas

In the field of psychology, very few studies deal with anticipation, the latter being defined as a paradoxical conduct. This paper describes a specific instrument elaborated by Mr Berta. The examined person is asked to imagine what he would wish to become in other life. Thus, he describes this imagery life that is located between two poles; one is rejected, the other ardently desired. Usually, this double attitude is illustrated by imagery. The negative pole (i.e. what the person is fighting) is actually what he does not want to become but as he struggles he actually develops in himself this unwanted, negative pole. The writers provide a clinical vignette, a woman called Mrs B. hospitalized for a depressive state consecutive to her husband’s death. Her protocole shows that she still is strong enough to integrate the bereavement. This way of organizing the psyche between the two poles thus having recourse to deep ethic values provides with innovating psychotherapeutic strategies.     

Le rapport au monde dans la maladie d’Alzheimer. Pour une lecture plurielle

Moving from a research sponsored by France Alzheimer, the authors try to question the Alzheimer disease from an anthropological, phenomenological and psychoanalytical point of view. This pathology has been always considered only from a neurological perspective, but it seems to us to be more complex, since it is the whole human being to be affected in it. The relationship to the world, the fear against death, the impossibility to afford the assumption of our fragilities, the signs of our finitude through time, the difficulty to accept the experience of the being out of step of our body show that the human singularity is affected by the Alzheimer disease. The intentional arc (tension) giving life to our existence is almost broken under the weight of an insurmountable anguish.     

Contribution à la méthode de recherche en clinique d’orientation psychanalytique : la lecture de l’inconscient et la discipline du commentaire de texte

The regular questioning of psychoanalysis constantly makes us seek answers to the current questions we have to deal with in our clinical practices. This article aims at contributing to our psychoanalytical practices research methods. Lacan based his teachings on the critical reading of Freud by advising us to take his texts into consideration. We think that his method, his “discipline of text commentary”, has its place in today's research both as far as transmission and innovation are concerned. Moreover, it enables psychoanalysts, who can thus be regarded as readers of the unconscious, to transform knowledge into creativity, by deciphering the powerful mystery of texts and theory.     

Catégorisation des interventions du psychothérapeute : construction d'un instrument regroupant différentes approches langagières

An essential issue for research in psychotherapy is a good knowledge of psychotherapists' interventions. Empirical studies have demonstrated that therapists' interventions are directly related to the results of the treatment and that they influence predictive factors of therapeutic success such as therapeutic alliance. For some fifty years, therapeutic interviews and their components have been studied in the light of various therapeutic theories and methodologies. Establishing a connection between investigation techniques would be useful in order to improve our understanding of these elements common to the various therapeutic treatments. This methodological study proposes to move forward along these lines. The first part of this article is devoted to the presentation of the principal methods of psychotherapists' speech analysis. We have drawn on currently available knowledge in the fields of linguistics and of psychotherapy research and presented our results in the form of a typology (non-linguistic approaches: hermeneutic and classification; formal linguistic approaches; functional linguistic approaches: pragmatic micro-analysis, linguistic clues, procedural approach, conversational analysis). The second part of our work aims to present an exploratory empirical study of psychotherapists' interventions. The objective of this empirical research is to build a new tool for analyzing psychotherapists' interventions on the basis of three instruments largely recognized in the field. Blanchet's grid (1991), Porter's classification (1950), and the Psychotherapy Intervention Rating Scale (PIRS, Milbrath et al., 1999) were applied to the same corpus (1,065 verbal interventions resulting from 8 therapeutic interviews carried out with two patients by a psychiatrist within the framework of Short Psychodynamic Investigation). The analysis of the frequencies of the 25 categories of the three grids starting from cross tables allowed us to identify common categories as well as categories specific to the three grids. The common categories were compiled and the specific ones were kept separate in order to shape a new synthetic instrument made up of 15 mutually exclusive categories. Three categories result from Porter's classification, seven from Blanchet's grid and five from the PIRS. These 15 categories were then grouped together into four classes according to formal and thematic criteria: 1) the “empathic interventions” group together four categories of Blanchet's grid (referential reiteration, modal reiteration, referential declaration, modal declaration); 2) the “search for information” interventions group together three categories of Blanchet's grid (instruction, referential interrogation, modal interrogation) and a category of Porter's classification (invitation with saying); 3) the “clinical interventions” group together two categories of Porter's classification (support, solution) and three categories of the PIRS (association, interpretation of defenses, interpretation of transfer); 4) the interventions relating to the “therapeutic framework” group together two categories of the PIRS (contractual arrangement, improvement of work). This new instrument shows that in spite of conceptual divergences and methodological specificities, the grids of analysis of therapists' speech share a certain common base. Thus, comparisons and connections between tools seem possible and very useful. Our new instrument of analysis of therapists' interventions has several advantages: integration of clinical and linguistic approaches ensuring internal and external validity, representation of various psychotherapeutic theories? After validation (study in progress), this tool could be applied easily and contribute to support the development of research on linguistic processes in psychotherapy. Such a tool could prove particularly useful for studying the specificity of psychotherapeutic interviews and differences in interventions according to therapeutic school.     

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.     

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.     

La pratique des entretiens préliminaires de psychothérapie psychanalytique: Critères d’évaluation - Étude quantitative

The practice of preliminary interviews is a field that researchers have little looked into until today. However, it is during those very first sessions between “the analyst and the analyzed” that is born the possibility of working out a psychoanalysis. This study deals with the practice of preliminary interviews in psychoanalytical therapies, based on the results of an empirical research that was carried out at the Pitié-Salpêtrière University Hospital and involved 30 therapists. The data for this study were collected, thanks to the therapists’ answers to a validated, standardized 36 items-questionnaire regarding what they could “hear” during the first sessions with their patients. The questionnaire was completed by 15 therapists with at least 10 years’ experience and 15 therapists with less than 5 years’ experience, and they answered regarding a patient they had seen two to five times. It covers five variables chosen according to their degree of involvement in their decision to follow that patient. An evaluation scoring sheet allows the psychoanalyst group to score the session, which has been tape-recorded. The results of the evaluation scoring sheet are the “objective” aspect of the study. The five questions regarding the five variables allow the therapists to evaluate whether or not they feel they have answered the questionnaire. Their own assessment of their clinical work is the “subjective” aspect of the study. The study focuses on the therapists’ mental work during the initial phase of the treatment: on what basis is the decision to follow a patient made? How important is the patient’s meta-communication skills at the beginning of the treatment and what do they mean to the therapist? Does it account differently for more or less experienced therapists? And what can we say about the analysts’ objectivity (the practice itself) and subjectivity (their feelings about the practice)? The data of our study show that, for all the therapists involved, the patient’s ability to meta-communicate matters very much to psychoanalyst. A comparative study allows us to account for the gaps or the overlapping between the objective and subjective aspects in both therapist groups. Finally, we noted that therapists with at least 10 years’ experience and therapists with less than 5 years’ experience functioned differently.     

Vécus corporels et psychiques : phénoménologie d’une unité

To be able to give up thinking about how consciousness could be naturalized means that neuroscientifics could make place not only to subjectivity, but more over to physical experiences such as emotions, affects, how they are felt, how they become history, how they come back.The phenomenological comprehension of the links between the physical and the psychical part of ourselves, the phenomenological comprehension of our psychosomatic unity helps the materialist explanations about the organism functions (brain included) to discover what the self means; whereas psychopathology has now to make up with the perceiving body experiences, a corporal subjectivity.If such an evolution could allow some kind of a dialog between these complementary knowledges, any pain and illness would have to be seen as both psychic and physical.