The Chronicle of Éric Laurent
Starts of the Clinic and the Dead-End of Neuro-Multiculturalism
The busiest forum on the current debates on the clinic has just taken place, from the 5th to the 9th of May in Philadelphia, with a well-chosen name. It was the 165th Congress of the American Psychiatry Association. The title and slogan of the Congress was: Integration. Between the General Practitioner and the hospital in a broader sense, how can psychiatric care be integrated into a system which is acquainted with the difficulties of public and private management networking, distinguished within different Health Maintenance Organisations, but not integrated within a unified health system? The system is also aware of the excessive prescription of psychotropic drugs by General Practitioners and the difficulty in integrating civilian and military psychiatry in the treatment of war veterans presenting post-traumatic syndromes.
Such a Congress represents 10,000 participants, with a profusion of everything: plenary sessions, workshops, round-tables, lectures, symposiums, guest speakers, key-note speakers, and a myriad of posters. It opened with a conversation between Aaron Beck, Emeritus Professor of Psychiatry in Pennsylvania, and Glen O. Gabbard, Professor of Psychiatry in the States of New York and Texas, on the points of convergence and divergence between cognitive and psychodynamic psychotherapies. Let it be clear: no slides, no texts, just speech, supreme luxury.
The program is 192 pages long, without counting the hundreds of poster pages. It begins with a 30 page Disclosure Index, in which the speakers who have had any action or engagement with pharmaceutical laboratories must declare them. It is also necessary that the speakers who have nothing to declare do so. The program evokes all that is said in the psychiatric field. It is very difficult to orient oneself in this democratic labyrinth, in which, nevertheless, there is a very strict pecking order. For psychoanalysis, it is easy; there is only one presentation in the program’s index, entitled: “Adolescence and childhood development reorganisation: A neuro-psychoanalytic model”. All in all, it is useful to refer to the specialised articles that appeared in the New York Times and the Washington Post in which Benedict Carey and N. C. Aizenman have resumed the main points.
In this Congress, there was a lot spoken about the consequences of the reorganisation of the clinical field, under the influence of the DSM-5 to be published in May 2013, and of the importance of this reorganisation on “integrated care”. The upcoming master is polarising the field already. The 162 member committee in charge of finalising the document has made public its strategic and highly political decision of renouncing two novelties which had made a scandal.
One of them was the new category of “attenuated psychosis risk syndrome”, which concerns identifying young people at risk of developing later on serious psychosis whilst suffering from minor hallucinations or delusional ideas. The greater risk was that they would be heavily medicated, at the price of unwanted side effects. Psychiatric classifications cannot offer themselves the luxury of admitting “ordinary psychosis” because it would be necessary to medicate them in an equally ordinary way. It also renounced to the new “Mixed Anxiety-Depressive Disorder” which opened up the way to placing the entire population under anti-depressants. We must not believe that these categories have been abandoned, because they have been proposed by the most fundamentalist sector of bio-psychiatry. They consider that pathology is probably one vast continuum in which clinical entities are nothing but unfounded rhetorical artifices, and that it would be better to distinguish degrees of intensity. These categories will then be placed in an ad hoccategory, which we have learnt about through HAS literature: “Disorders requiring further research”. Nevertheless, it is a failure of the Big pharma lobby. Allen J. Frances, President of the committee that developed the DSM-4, now at the head of the opposition movement against diagnostic extensions, is delighted about this drawing back but he underlines that there are still a certain number of categories likely to provoke adverse effects, like the “minor neuro-cognitive disorder”, or the too easily accepted “addiction”. He declares to Aizenham: “The implications go much further that anything that you have ever imagined (…) Add a new symptom and suddenly tens of millions of people who have no diagnosis up until now wake up with this one and will be bombarded by television adds proposing medical treatments… Instead of curbing the problem, the DSM-5 will open up the floodgates even more”. The fact that they are obliged to add a paragraph distinguishing sadness and the symptoms accompanying significant loss, which may resemble depression but isn’t, is hardly reassuring.
There is one point on which the DSM-5 committee made the decision of drastic reduction. It is on autism, where they propose to suppress “Asperger’s Syndrome” and “Pervasive Development Disorder Not Otherwise Specified”. The effects of this decision have been the subject of lively debates. A study from Yale considers that the number of autistic subjects will decrease by half, while another study presented during the Congress considers that this will not change much, as far as the current figures are concerned. As diagnosis is essential in order to access government benefits, the Director of the Centre of Childhood Studies of the Yale School of Medicine hopes that the last hypothesis is true and that the situation will remain stable, but he then wonders what is the point in touching it. However, one of the DSM-5 committees, whose declarations we have reported in another chronicle, (“Autism: Epidemic or Ordinary State of the Subject”, in LQ no. 194 of the 10th of April) was very clear on this point. It is a question of changing the definition in order to “stop the autism epidemic”. One deduces then that this will not be easy and will give rise to claims and predictable debates.
The entire Congress of psychiatry was thus subjected to the tension existing between extension and contention. On the neuroscientists’ side, liberated from clinical problems and based on the objectivation of neurobiological variations affecting autistic subjects, they voluntarily free themselves from limits. Laurent Mottron’s article published in the last issue of “Cerveau et psycho” is exemplary in this regard. “Everything that we know today about autism leads us to see in it a different brain organisation rather than an illness” and that “it is probable that the “autistic spectrum” (…) represents a large part of the population (…) A recent Korean study showed that an individual can correspond to the behavioural criteria of autism as defined by the scientific community, whilst being totally autonomous and without his peers noticing anything. This would be the case for more than 2% of the general population, on top of the 1% for whom the difference is evident. Are these individuals “autistic”? They are, if we define them by a particular behaviour; they are not, if we define them by an illness.
Here we are then at 3%, one child in thirty, which is to say, with the gender dissymmetry, about one boy in twenty. This “considerable population”, according to this perspective, must be welcomed despite its difference and have access to knowledge through their own means, in a way that optimises the performance of its members. It is only then that we will know what autism is, because for the moment “we do not know how autistics would behave if they had access, from birth, to the right information.” The autistic community is explicitly compared to the slave community of the colonial era. Cognitive studies concluded for a long time on the supremacy of western populations, when it was nothing more than exclusion from knowledge. It is not about adapting the autistic community to a lifestyle of the majority or wanting to efface their difference with artificial behavioural treatments. In the Canadian tradition of inter-community respect, Mottron proposes a neuro-communitarianism: “The demand to adapt oneself to the majority, founded upon the logic of strength in numbers, is the warfare’s logic, or electoral logic. It should not concern the neurobiological differences that exist within the human family”. It is about finding the right place for the members of this community. Mottron really does not t like psychoanalysis and never misses an opportunity to make it known, with a lack of subtlety worthy of praise. Nevertheless, the psychoanalytic objection to the community of subjects gathered under a common label should be of interest to him. What we can say about one subject of a given type is of no use for another subject. What needs to be aimed at is not the community, but the particularity. This is underlined by TEACCH practitioners, like Bernadette Rogé, Professor at Toulouse-Le Mirail University, interviewed by Mediapart, who says we must take into account the particularity of autistics: “their willingness, their motivation, their particular sensory and cognitive functioning, which demands a lot of adaptation”. Or even, in the “Denver model” where play and learning are combined in a “positive emotional interaction”, “every domain is worked upon: language, adaptation, motor functions… in a much more natural and spontaneous way”. Beyond objections in favour of singularity, neuro-communitarianism comes to a dead-end due to its vocation of extension without any limits, beginning from behavioural traits, thus sharing the same neurological malfunctioning not otherwise specified, which is no longer a symptom.
In the same issue of Cerveau et psycho, Franck Ramus, another supporter of the disappearance of the clinic in favour of neuro-scientific evaluations, dreams of another proliferation. He brings forth l’hubris from the French politician Fasquelle who seeks to legislate on the treatments of autism. He goes even further, calling for the creation of a “National Evaluation Agency of Psychotherapies” by leaning on the argument that we know so well since the Accoyer Amendment: the juridical void. “Non-pharmaceutical treatments are not subjected to any obligatory evaluation, and are put onto the market with no form of control”. He very much sees himself as being the one to watch over the prescription of any obligation, the validation of established treatment lists, updating, as if competent in the entire psychical field. A truly complicated project. We can see the contradictions into which the AFSSAPS has blundered, now the ANSM, when its domain was already well defined: that of biological studies. We learnt of the failure of the regulatory project for the title of Psychotherapist (the decree of May 7th 2012 modifying the decree of May 20th 2010 with regard to the use of the title, cf. the communique in Lacan Quotidien of 9th May). One easily imagines the dead-end in which this new Agency will be getting lost.
Franck Ramus boasts about not being a clinician and of only being orientated by “science”, that is to say, the horizon of the statistical series of “evidence based medicine”. He is the Research Director of the CNRS (National Centre for Scientific Research) in France, and also a member of KOllectif January 7th, a support group for the Le Mur (The wall) documentary, and “a reflection group on the theme of therapeutic practices for autistic children, so that they may progress despite the resistance of many psychoanalysts”. The leader is Brigitte Axelrad, Honorary Professor of Philosophy and Psycho-Sociology, author of a book on “The Ravages of False Memories” (2011) who sustains very different theses to those by Jean-Claude Maleval1 on the causes of the “false memories” epidemic. In this collective, we also come across Yann Kindo, Professor of History and Geography, a rationalist militant whose blog, housed by Mediapart, fires away at psychoanalysis and recommends civil disobedience in order to “become a voluntary planter of GMOs”. On May 10th 2012, loyal to the recommendations of the “Manifesto for an evidence-based psychiatry and psychology” produced by KOllectif, Franck Ramus published, in another blog housed by Mediapart, an article proudly entitled: “Psychical suffering is neither evaluable nor measurable”. My eye! He reaffirms there his faith in the validity of statistical investigation to measure everything that is psychical. However, in the dossier consecrated to autism in the April 2012 issue of Sciences et avenir, he could not hide his surprise over the little impact that the KOllectif “Manifesto” had when he had wanted to have it signed as a petition in his circle. The cause of this would be simple: “According to him, a lot of young psychiatrists would consider it too risky for their career to say out loud what they think deep down about French psychoanalysis”, the S&A dossier reports. We have here two links of the chain of the subjective field. Everything that is psychical can be measured, and if something unpredictable appears, this is the result of a psychoanalytic conspiracy. The fact, the evidence, is that the “manifesto” was a flop. The rest is interpretation.
Translation: Frances Coates-Ruet
(1) Maleval, J.C. Etonnantes mystifications de la psychotherapie authoritaire. (The astonishing mystifications of authoritarian psychotherapy)