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Goldman, D.L. (2007). The Role of Clinical Psychiatry in the Psychoanalysis of Severely Disturbed Individuals. Canadian J. Psychoanal., 15:77-92.

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(2007). Canadian Journal of Psychoanalysis, 15(1):77-92

The Role of Clinical Psychiatry in the Psychoanalysis of Severely Disturbed Individuals

David L. Goldman

Through vignettes, the author discusses three aspects of clinical psychiatry's potential involvement in the psychoanalytic treatment of individuals with severe and persistent problems with impulsivity, poor affect regulation, and impaired ego boundaries. First, the timely use of instrumental technologies such as rating scales and self-inventories may reveal Axis I diagnoses that require targeted psychiatric care. Second, the effect of combining neurobio-logical approaches such as psycho-pharmacotherapy with psychoanalysis may not necessarily be additive therapeutically. Freud's point of view, still relevant today, in these complex matters is discussed with a contemporary focus. Finally, the tendency of severely disturbed patients to express themselves self-destructively may burden the process of psychoanalytic listening with distractions from inside and outside of the analysis. Despite Freud's injunctions, psychoanalysts need to be ready to use psychiatric-style parameters, especially early in treatment, to address the demands of these turbulent patients and enhance their engagement in the psychoanalytic process. These clinical points reveal that the compromises psychoanalytic practitioners negotiate between psychoanalytic and psychiatric models in dealing with these severely disturbed individuals can lead to unforeseen treatment dilemmas.

A l'aide des cas cliniques, l'auteur décrit trois aspects de l'implication de la psychiatrie clinique dans le traitement psychanalytique des individus de psychopathologie sévère et persistante. D'abord, l'emploi de technologies instrumentales telles que des échelles et des inventaires a la possibilité de dépister une diagnostique qui exige un traitement psychiatrique spécifique.

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Deuxièmement, on doit se rendre compte qu'ajouter une approche neurobiologique comme la psycho-pharmacothérapie à l'intérieure d'une psychanalyse pourrait avoir des suites imprévues. Enfin, des tendances autodestructrices de ces patients turbulents risquent d'accabler indûment le processus de l'Écoute psychanalytique. Pour en faire face, malgré l'interdiction de Freud qui prône une division de travail entre psychanalyste et psychiatre, les psychanalystes devraient considérer l'emploi de certaines approches psychiatriques, surtout au début de l'analyse, pour permettre le déroulement du processus psychanalytique. Ces points cliniques sont révélateurs de l'imprévu dans le rapprochement des connaissances psychanalytiques et celles de la psychiatrie.

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