Réflexions sur le cadre thérapeutique et l’institution : médiatisation et caractère partiel

Abstract

The present epoch is no longer focussed on institutional psychotherapy, but it nevertheless continues to condition clinical practice and is still present in the various institutions in the form of a partially suppressed historical sediment. The present epoch, on the contrary, produces the ‘‘answer’’, provides solutions for reality, fills in for it, and even covers it up. An offer to listen, a project, a protocol, a response, a fantasized ideal bi-correspondence between a problem and its solution, a fantasy that is linked to the development of social discourse appears to be progressively conditioning and directing the organization of the mental healthcare structure. We have used as a basis for this study an aspect that is closely related to the organization of mental healthcare, i.e. the therapeutic approach, to examine the possibility of encouraging respect for the vulnerability of the patient, which, apart from the ethical considerations involved also has its therapeutic implications. We have attempted to define the concept of a therapeutic context in order to analyze it, and have proposed a model based on its partial character. The context is considered both under its ‘‘general’’ aspect (applicable to all) and its specific aspect (the focus being on one subject, or invented by the institution for its sole use). The singular context appears to consist of one that identifies, provides support, can be adapted to the situation and its development, and is interpretative. Moreover, its partial character (the epi-context, which provides support at the institutional level) can be viewed as one that gives the the subject the means to subsequently develop his own context and system of identification (the hyper-context). A representative clinical case has been included to illustrate these hypotheses. Finally, we have postulated that the partial nature of the epi-context provides the patient with the creative space and stimulus necessary to develop the hyper-context, i.e. firstly adjustment, then secondarily a means of establishing his own landmarks, and developing his own context and sense of identity. Thus, the hyper-context can be viewed as a form of open-ended questioning on the nature of the case, that is to say its relation to symbolization.