La réponse institutionnelle à l’anorexie mentale

Abstract

AimsThrough this article, we question the relevance of institutional responses and their implicit theories in the care of patients with anorexia nervosa. We demonstrate the interest of thinking about a care framework based on psychoanalytic theory in a context where the safeguarding of subjects’ narcissism is often centered on the body. MethodWe draw on our clinical experience in a psychiatric hospital for adolescents and young adults. We start from the question of the body, which is at the center of this pathology. Faced with a body—a body on display, a body that has lost its capacities for containment, and that is a site where psychic survival is at stake—, we question the different forms that the institutional response can take : a protective shield role, a role of containment, a role of differentiation between “inside” and “outside.” These institutional responses are evoked by relying on analytical theory, while trying to think through the object relationship—experienced by these patients as never satisfactory. ResultsWe see the importance of defining a framework of care that is different from the concept of the “contract.” A framework of care that should be discussed with the patient, giving them time to take ownership. We insist on the institutional work and the notion of institutional transfer so that the teams can manage these patients’ destructiveness, without feeling as if they themselves are destroyed. A clinical example emphasizes the importance for patients to find a form of autoeroticism when they are alone with themselves. DiscussionSeparation from the environment is often criticized in the management of anorexia. We observe that separation allows the institution to play the role of auxiliary self in a context where the object relationship is experienced as insufficient and/or intrusive. ConclusionIt is important for an institution to define its implicit theoretical approach, in particular in the management of adolescent pathologies. The psychoanalytic approach allows us to better understand destructiveness and the issues of psychic survival. It is a precious tool in constructing a relationship with the patient and in helping her/him out of her/his internal chaos.