We will approach the question of the therapeutic effectiveness of psychotropic drugs in adolescent psychiatry from a double perspective: a meta-psychological one, using the historical works of psychiatrist-psychoanalysts, and a clinical one, using our daily practice of adolescent psychiatry. Since psychotropic drugs were introduced in psychiatry in the 1950’s, research has focused on metapsychological models of the effect of psychotropic drugs and on the place of the prescription in the transference-countertransference relation. Using clinical vignettes, we show that psychotropic medication is a tool in the relation with the adolescent, a psychotrope whose effectiveness can not be conceived of outside of the relation dynamic that is at work.
The aim of this article is to offer some thoughts about the place of the pharmacological prescription within the framework of the institutional treatment of children and adolescents who present severe psychological disorders. Far from being a simply technical approach, prescribing medication to an adolescent within an institution corresponds to the construction of a transitional space which is the fruit of the encounter between the adolescent and the staff. The action of the psychotropic drugs must be inscribed in the overall psychical economy of the subject, taking into account the relationship between medication and the question of dependence and the inevitable issues of mastery and control that this engenders in adolescence, which are amplified by the institutional setting. Lastly, it is important to emphasize that this problematic must not be seen as confined to the specific institution which receives the adolescent, but applies more widely to the different institutions and referents which deal with the adolescent in the perspective of a multi-focus treatment among institutions and a longitudinal and parallel conception of treatment.
If there one really complex subject in psychiatry, it is the prescription of medication and the analysis of its objective and subjective effects, particularly in the adolescent, for whom the use of psychotropic drugs is relatively recent, even though it has quickly expanded. The model of institutional treatment developed here rests on the theory proposed by experienced practicians: the institutional therapeutic setting is metaphorized as a transitional space. The medication is therefore conceived of as one of the concrete objects which will allow for mediation of the bond and the establishment of a common, malleable object within the transference relation with the young patient. We discuss the possible pitfalls of the prescription and try to highlight its subjective and intersubjective aspects. If the medication must allow for the containment of intra-psychical drive activity that is too overwhelming for the adolescent, it should nevertheless not be used as a tool to obtain mastery or control over him. A « well-tempered » use of psychotropic drugs would enable one to work usefully with the patient on his inner conflicts, within the institution.
Psychiatric epidemiology raises a number of problems : the necessary operationalization of what is a mental disorder ; the conceptualization of what constitutes a risk factor, etc. These problems are not entirely solvable, but are nevertheless not enough to hamper the collection and interpretation of results, some of which are presented in this article.
Adolescence is a key period in the development of brain circuits that underlie the regulation of affects and behavior. Research on neuroimaging allows for a better understanding of the courses of normal and pathological brain development in adolescence. Thus, modifications of normal development seem to be implicated in the physiopathology of disorders like schizophrenia and various forms of depression.
The avatar may be treated as a double of the self or as a companion, a guide whom one follows or a slave to whom one gives orders. But in any case, its owner is invited to engage here in three complementary forms of symbolization: sensory-motor, imaged, and verbal.
Thus it can embody a fragment of oneself, a person one has known, admired or feared, even someone that one has imagined on the basis of stories one has heard or a family legend. This exploration can enable the construction of a potential space or, on the contrary, foster disavowal. Asking a player to speak of the choice and the history of his avatar is an essential moment of psychotherapy.
Video games and educational computerprograms prove to be excellent supports for the clinical observation of behavior and of the man-machine relation. Children and video games inspire us to ask new questions about the transitional space they create. The virtual world is able to reveal how the subject interacts with his environment. What results from this are new hypotheses about the quality of perceptions and the apprehension of the object in the construction of the Ego and its emotional future.
In the past twenty years, video games have become firmly entrenched in our culture. Adolescents find in them spaces in which adolescent issues can be played out and re-played. Psychotherapists have started using them within the framework of therapeutic mediations. This paper reports the construction of a therapeutic arrangement: video game group therapy. This is conceived of as a working apparatus allowing for the stimulation and reception of affects and thoughts. This type of mediation is particularly interesting in the treatment of children and adolescents whose total inhibition initially compromises the therapeutic project. The notion of « ludo-landscape» characterizes a part of the psychical work which is summoned up by the video game. The case of Julien illustrates the work that was carried out.
For over-playing teenagers, the association of a videogame workshop and a talking moment seems to be an adequate therapy. The use of the videogame as the mediation object of the therapy allows for the emergence of feelings that might be elaborated through verbalization in a second step. It allows the teenagers to become aware of their own troubles, and consequently helps them to move away from them. Interactions facilitated by the well-disposed group strengthen the identificatory process, especially with the victims of school violence. At least one of the therapists should be very familiar with the videogame’s world, in order to facilitate the narcissistic revaluation process and the identification process.
The polemic that certain web sites give rise to is all the more enthralling in that this tool signals a real rupture in the nature of investments between the new generation and the old. The turnabout in identity transmission positions is one of the avatars generated by the invasion of avatars with the family unit. Freud wrote a few words about the telephone at the time of « Civilization and its discontents ». What would he say about Second Life in our « Crisis in the Culture » ?
Adolescence, 2009, T. 27, n°3, pp. 679-687.
Revue semestrielle de psychanalyse, psychopathologie et sciences humaines, indexée AERES au listing PsycINFO publiée avec le concours du Centre National du Livre et de l’Université de Paris Diderot Paris 7