Psychodynamics

We are presenting a 53-year-old single, Chinese born Kelantanese from Kota Bharu with a diagnosis of Paranoid Schizophrenia for more than 25 years who is a graduate in Arts from Nanyang University.

This presentation is going to highlight
(1 ) The influence of intelligence on the sophistication of delusions
(2) The evolving erotomanic delusions
(3) How the patient identifies the erotomanic object as a persecutor who appears in various disguises, in the form of letters as one of the means for communication.

Eliciting psychopathology through patient's writings is underutilized in daily psychiatric practice, which is dominated by undereducated, less privileged schizophrenic patients

The aim of this paper is to add to existing work on the theme of power, emotion, and organizational learning. The study was undertaken in Kazakhstan, where tensions between old and new regimes provide an environment that is rich in emotion and power/politics; and offer an opportunity to study the interplay between emotion and power during individual and organizational attempts to learn. The social unconscious is used as a conceptual frame to identify underlying dynamics that impact on organizational learning. The empirical study illustrates a social fantasy concerning the fear of mistakes and its consequences. This fantasy is sustained through blaming and punishing the people who make mistakes, and through feelings of internalised embarrassment and guilt that are enacted through interpersonal relations of shaming and being ashamed. Our contribution to knowledge arises from employing a concept (social unconscious) that has not been used to study organizational learning within a social and organizational context for organizational learning (Kazakhstan) that has not yet been studied. The practical purpose of this paper is to improve our knowledge of the social and political context of organizational learning in post-Soviet Kazakhstan through understanding unconscious dynamics that both inform and undermine attempts to learn.

Résumé

Le but de cet article pourrait être de revisiter les concepts théoriques qui portent sur les aléas du travail de séparation psychique chez les adolescents gravement suicidaires en s’appuyant sur une situation clinique particulièrement éprouvante. La position « intraitable » de ce jeune patient semble en effet témoigner de la validité de l’hypothèse soutenant que la recherche active de la mort peut constituer un moyen de renouer avec un état d’indifférenciation. Tout se passe en effet comme si la disparition du sujet constituait la condition requise pour échapper aux tourments d’une conscience séparée, et récupérer ainsi, sous couvert d’un fantasme de fusion, l’amour inconditionnel des objets primaires. L’enjeu thérapeutique pourrait être d’accompagner les adolescents pris dans ce piège narcissique dans une élaboration de la honte liée à leur corps sexué et aux sentiments ambivalents éprouvés à l’égard de leurs parents, afin qu’ils soient moins en nécessité défensive de soutenir cette mortelle quête d’union symbiotique avec « l’objet primaire ».
Abstract

Clinicians who work with hospitalized teenagers often face some young patients’ relentless suicidal determination: these patients seem to have sentenced themselves to death. For several months, sometimes years, no one manages to revoke this incomprehensible capital punishment. This painful conviction that they are unworthy often comes with depressive affects that resist on a long-term basis, despite the combination of antidepressants and a psychotherapeutic approach. Thinking is too stressful: they long to suspend any psychic life, to stop the emergence of any desire and to end any relational impulse. They keep trying to stay in a factitious world, far from real life requirements, as a temporary alternative to death. Through the anaesthesia it produces, the use of drugs offers them a strong protection from their pain. The regressive search for a feeling of lacking psychic differentiation seems to confirm a defect of development within the first phase of the separation individuation process. Narcissistic vulnerability is often underlined in most psychopathological studies concerning suicide attempts during teenage years. Combined with the incapacity to endure any loss, this last element seems to imply that a “relationship of encroachment” exists between the subject and its environment, as well as a persistence of a broad area of lacking differentiation within the maternal imago. From this theoretical point of view, suicidal gestures from these patients are often understood as desperate and paradoxical attempts to reach their boundaries, to maintain their identity and to “withdraw themselves from the object of alienation”. These relevant interpretations hide the “search of a narcissistic state of undifferentiated union” that F. Ladame highlighted during the psychoanalytical counselling of numerous young and seriously suicidal patients. Through this article, we propose to try and re-examine the theoretical concepts related to the ups and downs of the psychic separation work needed by teenagers, particularly for those who went through serious suicide attempts. The presentation of a particularly difficult clinical situation will help us bring context to our subject. The uncompromising posture of this young patient seems to give credence to the hypothesis claiming that the active pursuit of death may be a way to reconnect with an undifferentiated state. In the case of our teenager, everything is going as if his disappearance was the only way to escape from the torments of a separate consciousness, and therefore recover the unconditional love from primary objects through the guise of a fusion fantasy. How can we guide adolescents caught in this narcissistic trap? The therapeutic challenge could be to guide them through the elaboration of the shame attached to their sexual body and of the ambivalent feelings they experience towards their parents. The aim would be to allow them be less dependent on their defensive way to support this deadly quest of symbiotic union with the “primary object”.

Scientific discourse and media coverage on the necessity of early detection and management of autism spectrum disorder (ASD) recently turned into a political pressure on the work of caregivers in public psychiatric institutions, summoned to adapt to the “international best practices”. Following the American AAP (2007), the French HAS (2012), the British NICE (2013), the Belgian KCE (2014) and finally the Swiss Federal Council (2015) have each edited national ASD related guidelines, focusing on cognitive behavioural therapies (CBT). In France and the French-speaking part of Switzerland, these recommendations are directly challenging public psychiatry, historically based on psychodynamic references.

The Swiss government recommendations were paralleled by the emergence of semi-public structures, competing with public institutions. In the Canton of Geneva, a specialised Autism Consultation Centre, created in 2009, launched two Early Intervention Centres between 2010 and 2015.  In the Canton of Vaud, an Autism Competence Centre was created in 2014, alongside with an academic Chair of Excellence, both privately funded. These structures use intervention models (ABA, ESDM, TEACCH) recommended by national guidelines, and thus impose a new framework of interpretation widely hailed by media and politics. Early diagnosis and intervention, objectifiable criteria and strong partnership with families are imperative in this framework. It is correlated with simultaneous disqualification of psychodynamic approaches and praise of CBT.

Our fieldwork reveals that “new professionals” (Eyal, 2010), supported by political authorities, are deemed the most legitimate to express a public opinion on the “right way” to manage ASD and subsequently require paediatricians to refer families to their services. A competition between autism-specialised services and general child psychiatry seems to account for significant decrease in ASD consultations that was observed in the former. In Geneva, the Department of child and adolescent psychiatry of the cantonal hospital historically lays on a psychodynamic ground, and currently attracts the wrath of the local parents’ association. At the same time, the Autism Consultation Centre is CBT-oriented and proudly displays its strong ties with the parents’ association, which claims that this service is more suitable for early management of ASD. Due to the proximity of this association with local politicians, the clinicians of the public service are instructed to refer their patients to this Centre. However, families are often addressed to both services at the same time, which creates an overlap in the management of ASD cases. This overlap paradoxically entails a loss of time: the two services barely communicate with each other and clinical exams are often performed twice. Moreover, the DSM 5 concept of ASD generates a complex situation where, from the psychiatrists’ point of view, many of the diagnosed children are not “real autists”, but actually get labelled as such in order to be eligible for a referral to specialised services.

While “autism centres” embody the tendency to highly specialise the category, the ASD concept accomplished quite the contrary. Highly specialised centres eventually treat little specific spectrum population and child psychiatrists feel they lost control over a diagnostic category that was crucial for child psychiatry.