How do you get into psychosis? ? This classic question of psychiatry can be reversed: why do we enter psychosis ? Distrusting hasty medical intervention, two authors seek to understand the passage from “ sweet madness » to clinical psychosis.
Over the past ten years, medical intervention programs in the early phases of psychoses have been increasing around the world. In Europe, the first detection networks for early onset disorders – Lausanne, London, Paris (Prépsy: mental health network for coordinating doctors for the detection and monitoring of young patients) – closely followed the founding of theInternational Early Psychosis Association which took place in Australia at the end of the 1990s. Identifying psychotic subjects as early as possible is certainly a constitutive principle of psychiatry: present in the minds of the alienists of the first XIXe century, it was reinforced by the theory of degeneration, then it was renewed by the mental hygiene of the interwar period. With the advent of the neuroleptic era (in the 1950s-1960s), consolidated by the use of antipsychotics from the 1990s, the practice of low-dose preventive medication for subjects in the phase of “ beginning psychosis » was imposed. The current definition of the modalities of entry into psychosis has become a social question whose interest certainly goes beyond the restricted circle of psychiatrists, since it is linked to the concern for risk prevention in a European society influenced by the health paradigm. mental health and in a French society subject to a security concept of psychiatry.
Criticism of psychiatry
How do you get into psychosis? ? Two books offer an answer to this question by overturning the foundations of the question: why do we enter psychosis ? Different in their forms (a pamphlet centered on a single case, a thesis based on a history of two centuries), these works offer, from a clearly stated psychoanalytic approach, a putting into historical perspective and a contemporary state of the situation .
Paul-Laurent Assoun and Yohan Trichet start from a critical observation with regard to the psychiatric approach: inscribed in the organicism of XIXe century, it developed a dry classification based, at the beginning of the XXe century, on the neurosis/psychosis divide and, within the latter, on the schizophrenia/manic-depressive psychosis couple. The two authors carry out the criticism on three fronts. The first criticism concerns the disappearance of the subject. According to Assoun, the standardized reading of the symptoms of the manic patient impoverishes the subjective dimension which must be part of the care. Can we summarize his state – the triumphant and jubilant mood, the extreme insomniac mobility, the hyperfreedom of language, the acceleration of thought – to a clinical picture systematically inaugurating the same medical protocol ? For example, should we so obviously oppose a manic being overflowing with affect to the melancholy being withdrawn into himself and the self-bliss of one to the self-reproach of the other? ?
The second criticism concerns the methods of early treatment of subjects who enter psychosis. The Canadian centers for the detection of early psychoses refer, according to Trichet, to the old alienist project of creating services for acutely delirious people, dedicated to shortening the non-medicalized duration of the illness as much as possible. If the preventive use of neuroleptics poses significant health and ethical problems – the presence of side effects always exists with the most recent molecules, even if they seem attenuated – we too quickly forget that these medications, wrongly called “ antipsychotics », do not attack the structure of psychosis, but reduce the symptoms in the same way as the first generation of neuroleptics. Indeed, no treatment allows the patient to return to the state prior to entry into psychosis: it is the very notion of healing which is therefore at stake.
The third criticism highlights the archaism of contemporary theoretical conceptions which underlie early interventionism in psychosis. As Trichet explains, since its construction in the late 1970s, the model “ stress-vulnerability », based on a bio-psycho-social representation of the appearance of madness, has become the dominant key to understanding psychotic disorders. The psychotic individual is considered to be genetically vulnerable and incapable of controlling the multifactorial stresses of modern society. In a society obsessed with risk management, psychiatry therefore helps to identify the most vulnerable in advance and to examine the prodromes of possible psychosis, even if these signs – depressed mood, concentration problems, sleep disorders for example – are necessarily not very specific in a beginner phase.
Assoun and Trichet both note the resurgence of historical models of XVIIIe century – the theory of humors – and XIXe century – that of predisposition – in the theoretical corpus implemented today to legitimize early psychiatric intervention. Is the representation of bipolar outlined in the 1950s – a mood disorder oscillating cyclically between a manic pole and a depressive pole – really indebted to the humoralist fluidic conception and therefore logically treated only by chemistry? ? Does the stress-vulnerability model only extend medical representations of the madness of XIXe century ? These two hypotheses undoubtedly deserve to be supported at greater length, but the historical questioning of contemporary scientific theories is certainly stimulating.
Postman Cheval’s stumble
What can we oppose to this mechanical, preventive and therefore expected representation of entry into madness? ? Assoun and Trichet, without ever falling into the idealism of completely ignoring chemotherapy, both talk about the need to understand the drama that occurs in the subject’s history and serves as a trigger for psychosis. Postman Cheval’s maniacal adventure begins with an unexpected encounter with a strange object that breaks his personal history by holding his attention for decades. The stone on which he inadvertently stumbles is an enigmatic sign of which Cheval interprets. Then the serialization of the stone object shapes the triumphal palace. Assoun does not look for prodromes of mania – there is no “ prehistory » by the postman Cheval – but gives the meaning of this brutal entry into a new life.
Ferdinand Cheval (1836-1924) is the self-taught architect of a monumental building classified as “ historical monument » since 1969. A syncretic palace forged by accumulation, like all spontaneous architectures, excessive in the details, the palace-tomb – because it is one – was built between 1897 and 1920 by this Drôme postman touched by multiple bereavements: orphaned at 19, Cheval lost his wife and daughter before beginning his (re)construction. The postman is not a maniac in crisis, but a melancholic “ which restores itself triumphantly » and slowly during the forty years of his new life. As Assoun explains, the subject sinks entirely into his symptom, this tomb palace, “ mausoleum of himself “, projection of his inner self, comes to cover the mourning of his first life. For Cheval, entering mild madness is a form of self-medication in a situation of failure of the work of mourning – the “ Horse remedy » – which comes, from an unpredictable enigmatic experience, to pose the question of the father. Far from being limited to clinical forms of eccentricity, mania appears, according to Assoun, as a “ fight back » of the subject against the object in the process of defeating him: “ The subject rises while collapsing. » Contrary to appearances, the manic subject is not joyful, he is made enthusiastic by the sudden removal of the melancholic obstacle which releases an infinite and joyful energy.
Triggering vs. appearing
Based on a very rich corpus and a clearly presented theoretical approach, Yohan Trichet shows how a Lacanian model of “ trigger » of psychosis is fundamentally opposed to the historical model of “ appearance » against the background of the subject’s predisposition. For the psychologist, under renewed names, has been taking shape since the XIXe century the same representation of the entry into madness: an insidious form (schizophrenia), more brutal (the delirious burst), warning signs (unmotivated laughter, visions, insomnia, transformation of the sound and flow of the voice, gestures unusual, etc.). The work of psychiatrists XXe century have systematized the predictable stages of entry into psychosis: initial perplexity, transformation of the subject’s relationship to his body and to the world, persecutory delirium, chronicity, dementia.
What the observations presented by Trichet – which here echoes Assoun’s remarks on the Horse factor – clearly show is the construction by the subject of complex scenarios which are so many imaginary crutches to prevent taking action. The transition to clinical psychosis is marked by an accidental cessation of this self-treatment. Entry into madness is the unpredictable fruit of a “ bad meeting » (a happy or unhappy event) with an unassimilable signifier (around the desire of the other, sexual demand). This initial perplexity associated with a feeling of imminent catastrophe leads the subject into a form of impasse. Faced with the absence of meaning, the subject issues a delusional and persecuted explanation with soothing virtues and which is akin to a revelation. The delirium therefore arises from a strategic logic of the subject, just as Horse’s mania is a solution to resolve the melancholic crisis of the postman. Entry into madness therefore results both from a structural deficiency of the subject (which is not a predisposition), from an unexpected bad encounter and from a failure of self-treatment through the delusional construction.
The urgency of speech
How to rethink care in this phase of entry into psychosis ? Both works have the merit of tackling this question head on. For Assoun, we must re-consider the various “ manic states » (drug addiction and bulimia for example) based on the metapsychological revision described in relation to the Horse factor. For Trichet, we must not be satisfied with emergency medication, but it is necessary to welcome an emergency of speech by backing off or moderating early medical interventionism and by being attentive to the subject’s story. The medication should not be an end, but a means to avoid acting out and to reduce the subject’s anxiety so that he can regain the ability to talk about his initial perplexity.
This “ subjective urgency » allowing us to evoke the triggering conditions specific to each subject and relying on its self-therapeutic construction is both revolutionary – it must overcome the mistrust relating to the analysis of psychotics – and anchored in the heritage of minimally interventionist expectant medicine from the beginnings of XIXe century as well as the first alienism, the one who at the same time wanted to become the secretary of madmen. Faced with the subject entering psychosis, Assoun and Trichet finally suggest taking what the subject says literally to capture the dramatic moment from which nothing is the same as before.