Dispositifs thérapeutiques à l’épreuve du dialogue entre réalité neurologique et réalité psychique

Abstract

ObjectivesClinical work with brain injuries (stroke, traumatic brain injury, tumor…) raises thorny questions from epistemological, clinical, and therapeutic points of view. The organization of a therapeutic setting for rehabilitation purposes often requires setting targeted objectives, but it is equally concerned with the patients and their psychical functioning as a whole. If the emphasis placed on the rehabilitation of disorders and deficits is important, the need to resist sacrificing the patient's psychical reality on the altar of the stimulation of cognitive functions, and of adaptive and performative concerns, remains a major clinical and ethical issue. MethodBased on their clinical experiences in neuropsychological rehabilitation, in private practice, and in psychotherapy in a rehabilitation department, the authors show how they were challenged by the movements inherent to therapeutic settings, seized by the singular psychical reality of their patients. Indeed, their lives disrupted by the experience of cerebral damage, as well as somatic and cognitive disorders, these patients are also confronted with the constraints of the setting of the rehabilitation work, with expectations in terms of efforts to be made, performances to be achieved, etc. At the same time, these patients are put to work both by the way their psychical reality is disturbed by this new and often unexpected event and by the way it deals with the trauma. Analyzing the changes observed in patients during rehabilitation or psychoanalytical psychotherapy sessions, the authors discern the way in which these different realities may collide, respond to each other, combine. ResultsThe diversity of the clinical situations shows how the present and material dimension of the trauma is not enough to account for the patients’ states of psychical suffering which may lead them, despite their good will, to mobilize behaviors of manifest opposition (aggressiveness) or latent opposition (depression) that interfere with the setting and the rehabilitation objectives. Indeed, the remobilization of past, unconscious psychical conflicts, linked to experiences of powerlessness, dependence, mastery, abandonment, plays a nodal role in the development of the therapeutic plan. These deferred actions make it possible to understand how cognitive difficulties are not reducible to neurological damage, and may be aggravated by the psychical conflicts reactivated during the proposed treatments. The reality of an accidental event meets the effects of internal motivations which may, unbeknownst to the patients, question their potential implication in the accident. Thus, clinicians can discover to what extent the neurological issue reinforces the psychical resistance to the potentialities of change and psychical elaboration, and vice versa. If not considered nor put to work, these psychical issues and defenses can constitute obstacles to the quality of the cognitive rehabilitation plan, to the rehabilitation of self-esteem, and even to the re-establishment of mental health. DiscussionCognitive disorders of cerebral origin encounter a psychical reality that is always singular, full of fragilities and resources. Only listening to the patients allows us to grasp what is bruised and revived in their psychical reality. This listening highlights the importance of a dialogue between neuropsychology and psychoanalysis, which cannot be totally separated from each other in a clinical context. Their combined perspectives allow the overcoming of a monolithic vision of the etiopathogenic factors and guarantee that the patient's subjectivity is taken into consideration. This is how therapeutic settings, challenged by the complexity of the patients’ cognitive and psychical functioning, allow the latter to put themselves to work by mobilizing a mental activity where both the cognitive disorders and the psychical processes treating anxiety and depression in particular are expressed. Thanks to their ability to use their psychical processes of elaboration of the trauma, the patients can soften their defenses and their resistances, thereby mobilizing themselves for the exercises of rehabilitation that remain necessary. ConclusionsAlthough different, and sometimes in disagreement, psychoanalysis and neuropsychology have as common object the singularity of each patient. The possibility of a dialogue allowing for a listening to the psychical causality while taking note of the brain injuries underlying the cognitive disorders proves to be a precious condition of clinicians’ capacity to accompany their patients in their torments and paradoxes. The quality of the care offered to these men and women, whose bodies and psyches have been damaged, depends on it: interdisciplinary dialogue within the same therapist or between two therapists is based on an alliance of theoretical and clinical rigor and flexibility, whatever the proposed setting.