Réflexions sur le cadre thérapeutique et l'institution : médiatisation et caractère partielRegarding the therapeutic context and the institution: mediation and incompleteness

Abstract

L’époque n’est plus à la psychothérapie institutionnelle, qui pourtant imprègne les pratiques ou subsiste au sein des institutions à la manière d’un sédiment historique et partiellement refoulé. L’époque a contrario, produit de la « réponse », solutionne, obture le réel, le recouvre. Offre d’écoute, projet, protocole, réponse, un fantasme de bi-correspondance idéale entre un problème et sa solution, fantasme lié à l’évolution du discours social, semble régir, progressivement, l’organisation des structures de soins. Nous partirons d’une dimension intimement liée à l’institution soignante, le cadre thérapeutique, pour discuter la possibilité d’un respect de la béance du sujet, qui, outre ses résonances éthiques, se prolonge d’effets thérapeutiques. Nous tenterons de définir la notion de Cadre thérapeutique, pour l’analyser et en proposer une modélisation basée sur son caractère partiel. Le cadre sera envisagé sous son aspect « général » (appliqué à tous) et singulier (adressé à un sujet, inventé par l’institution pour lui seul). Le Cadre Singulier apparaîtra identifiant, étayant, contenant et interprétatif. D’autre part, son caractère partiel (Epi-cadre) sera entendu comme permettant l’élaboration par le sujet de son propre cadre (l’hyper-cadre). Un cas clinique succinct viendra illustrer notre propos. Nous poserons enfin l’hyper-cadre comme mise en acte pour interroger, sans répondre, sa nature, c’est à dire son rapport à la symbolisation. 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.