The place of psychoanalysis in French psychiatry.

France is known as one of the countries where psychoanalysis still holds an important position in various fields, and specially in psychiatry. Is it a 'culture bound syndrome' of French society, or, more seriously, a particularity that could be useful in other contexts as well? Through consideration of the role psychoanalysis is playing in French psychiatry, this paper will try to review this particularity and its interactions with the organisation and values of psychiatry in France, both in the public services and in private practice.

France is known as one of the countries where psychoanalysis still holds an important position in various fields, ranging from psychiatry to philosophy through psychology, medicine, sociology, education, art and literature. Its influence can be identified in areas that are intuitively considered as being quite opposed to psychoanalytic thinking, such as neuroscience (Naccache, 2006) and politics (Ménéchal, 2008). This exceptional influence has sometimes been seen as an object of investigation in itself (De Mijolla, 2012). Some consider it to be a ‘culture-bound syndrome’ of French society, characterised by secularism and the importance of the role given to ‘intellectuals’ since the Enlightenment. Others think it is a consequence of the weakness of French universities in opening themselves to the international context, due either to language barriers – that is, the reluctance to consider English as the lingua franca of the globalised world of science – or to the lack of democracy and strictness in their organisation and in the selection of academics. The issue of whether this specific aspect of French cultural life is an archaic remnant of times when authority arguments prevailed upon real evidence-based science, or represents a heroic resistance of intellectual complexity against reductionist globalised Anglo-Saxon pragmatism, is frequently debated. For example, the question is frequently raised, implicitly or explicitly, on some late-night cultural talk shows on French television.

Controversy within the French psychoanalytic movement

Controversies can also be observed inside the French psychoanalytic movement, which is split into two factions with opposing perspectives.

The older, classical faction is represented by the French psychoanalytic societies that are members of the International Psychoanalytic Association (IPA) and which label themselves as Freudian (Société Psychanalytique de Paris, Association Psychanalytique de France). Owing to the seniority of these societies, their strictness in selecting and educating trainees and postgraduates, and their regular external scrutiny by the IPA, they are considered to be the more strongly established and most recognised of the French psychoanalytic schools, even if they represent only a small part of the psychoanalytic offer in the country (no more than one-third of the psychoanalytic offer in private practice).

The newer and more radical faction is represented by the constellation of Lacanian schools (Roudinesco, 1982; 1986). French psychoanalysis is strongly influenced by the Lacanian perspective, and indeed this perspective is frequently caricatured as the ‘real’ French psychoanalysis. Created by Jacques Lacan in the mid-1950s, this movement was rapidly excluded from the IPA. Since then it has gone through multiple divisions that have given birth to several Lacanian schools based around various Lacanian masters. It forms the largest contingent of French psychoanalysts, who are still not recognised by the IPA but, nevertheless, are recognised as psychoanalysts by the French administration. The Lacanian perspective advocates a ‘return to Freud’, adopting a structural reading of his theoretical stances through an application of linguistic findings to the understanding of the unconscious functioning. Strikingly, Lacanians frequently raise this stance as a resistance to the ego-psychology perspective of American psychoanalysis, which they see as a deviation from the original Freudian theory. Originally often connected to Structuralism and Marxism, the Lacanian perspective has been particularly influential in many French social and philosophical studies.

Although this debate was highly controversial between the 1960s and the 1980s, when psychoanalysis was at the top of the agenda, since the early 1980s it has lost its strength as the influence of psychoanalysis has lessened. It has since been replaced by a fierce controversy between psychoanalysis and cognitive–behavioural therapy, even though the latter is much less widely disseminated and used in France than in most other high-income countries in Europe and elsewhere.

Psychoanalytic concepts within psychiatry in France

In this context, French psychiatry still claims to be characterised by its desire to remain a psychotherapeutic discipline. References to psychodynamic theories are still quite commonly made and are often mixed with a background rooted in the continental phenomenological tradition, mainly its German version. In addition, following Freud's assumption that psychoanalysis is not only a psychotherapeutic technique but also a method to investigate mental processes and a set of theories built on this method, most of the French psychiatrists working in public psychiatric wards consider that such references are useful in modern psychiatry and in the design and functioning of therapeutic programmes for severely impaired patients.

This point of view accounts for the observation that, although very few French psychiatrists think that psychoanalysis contributes to the understanding of the causes of psychiatric conditions such as psychosis or bipolar disorders, they consider that psychoanalysis is still:

a theory for the psychopathological processes involved in these conditions;

a tool to analyse these processes and the part played by the relationship between patient and physician in changes that occur in the patient's disorder;

an inspiration for psychotherapeutic techniques derived from the psychoanalytic model – techniques that are often proposed to many patients under various names (psychotherapies, cognitive remediation, psychosocial rehabilitation, health education, recovery, etc.).

For example, it is very common for many French psychiatrists to use psychoanalytic concepts to understand and elaborate attitudes within the therapeutic team that are induced by patients, applying to institutional settings the model of transference and counter-transference. There are two reasons for this approach. First, it aims to reduce staff burnout, with the idea that it will help team members avoid relational vicious circles that replicate patients’ relational patterns. This is, of course, a major contribution to treatment of patients with severe psychiatric disorders in settings involving team work. Second, some teams consider that, with the use of such analytic tools, a milieu therapy may become a psychodynamic psychotherapy by itself. This assumption is based on two core ideas:

that treatment of patients with psychotic disorders is not exclusively limited to the patients themselves, and that psychotherapeutic action may involve the psychic environment interacting with patients in everyday life as well as in therapeutic settings;

that relation to a therapeutic frame is the ‘royal road’ to interacting with patients’ inner life, and offers the best possible way to use a psychodynamic psychotherapeutic approach with patients with whom more classical psychoanalytical approaches are generally impossible or risky.

Although French psychiatry is influenced by the current main stream nosographic model based on the DSM, French psychiatry is more reluctant than other psychiatries to adopt it. Indeed, French psychiatry considers that the DSM nosographic model is not well adapted to following up the psychotherapeutic techniques it uses and values (Landman, 2013).

Practical consequences

This situation is having practical consequences for many issues affecting the future of psychiatry in France (Botbol & Lehembre, 2008).

The first of these is the workforce. To date, France has been second or third in the world for psychiatrist density (nearly three times as high as the UK, for example), with about 13 500 psychiatrists for a population of 60 million (Clery-Melin et al, 2002). Nearly 7000 of these psychiatrists are engaged in private practice, meaning that many of them devote most of their time to practising individual psychotherapy. A survey carried out in 1994 (Lehembre, 2004) found that around 50% of these psychiatrists present themselves as psychoanalysts and declare that they are treating 70% of their patients through weekly psychotherapeutic sessions, which are widely reimbursed by the national health insurance system. This model is obviously dependent on the relatively high ratio of psychiatrists to the general population, and it is being directly affected by the government objective to reduce the ratio of psychiatrists in France, to catch up with the UK's ratio. Following this trend, the number of psychiatrists in France could be 40% lower in 2020. The French administration is trying to find a solution to this problem by limiting reimbursement for mild psychological distress and by promoting psychologists working in psychotherapeutic functions in the psychiatric therapeutic network. This approach is being fought by many psychiatrists who see it as a major threat to the psychotherapeutic orientation of psychiatry in France.

A second issue is education. There is a strong commitment to modernising pre- and postgraduate psychiatric education to bring it closer to evidence-based data and research. However, the current main debate concerns training in psychotherapy. This controversial issue is dividing those who think that this training should be as diverse as possible and strongly related to psychiatric education, particularly when designed for non-medical professionals, and those who believe that it should remain in the hands of private scientific associations developing their own perspectives and regulations.