CLINICAL LOGICS

2021_3

 

Deadline for manuscripts : april 2021


P
sychoanalytical reasoning – as a language and an argumentation following certain formal rules – has not been the focus of in-depth studies, allowing its translation into logical proposal. Based on the interpretation of the singular – although it unfolds in various forms (diagnosis, etiology, metapsychology) – the reasoning in question seems to differ from other types of logic (formal, experimental). This is the reason why some psychoanalysts claim an extraterritorial epistemology, emancipated from any scientific approach. The epistemological extraterritoriality of psychoanalysis nevertheless questions theoretically and clinically. It questions whether there are common and/or differential features in terms of logical procedures between clinical, research, medicine, human and social sciences, experimental sciences, etc.


As for the adjective "clinical", it is used today in various meanings, to the point that its definition is less and less clear. What is there in common, for example, between the so-called "clinical" approach in psychology (Lagache, 1947; Prévost, 2003) and the one in cognitive-experimental psychology, both of which claim a form of "clinicity" (McFall, 1991)? But furthermore, what do these different "clinical" psychologies have in common with the "clinical" method in the human sciences (Revault d'Allonne et al., 1989) or, even more broadly, "clinical thinking", in the sense of "case by case" thinking, indexed to singularities (Passeron and Revel, 2005; Lacour, 2006, 2020)?




In the field of health care, a major issue for contemporary societies, an epistemology of "clinical" thought has gradually been established to redistribute and differentiate the problems and logics at stake. But while such a reflective process clearly takes place in somatic medicine (Fagot-Largeault, 2010; Giroud, 2011; Basso, 2014; Lefève, Mino & Zaccaï-Reyners, 2016; Lemoine, 2017), in psychiatry (Lantéri-Laura, 1991 ; Demazeux, 2013; Berrios, 2019) or in psychology (Danziger, 1990, 1997), fewer works are available in psychoanalysis (Laplanche, 1987; Widlöcher, 1996; Green, 2002; Arminjon, 2013; Poenaru, 2018; Visentini, 2019). This issue therefore proposes to question the multiple clinical logics of the field of care, in a comparative and critical perspective.


Traditionally, in medicine - since Claude Bernard -, "clinical" is opposed to "experimental". At the turn of the 18th and 19th centuries, medicine was in the first place "clinical", based on the observation of cases "at the bedside", describing them, typologizing them, and then generalizing from them. In the 19th century, an "experimental" medicine was added to the first one, proposing to prioritize the objective signs of diseases, in relation to symptomatic sensations (Canguilhem, 1988). Thus, Bernard writes in his Introduction to Experimental Medicine: « The physician's subject of study is necessarily the patient, and his or her first field of observation is therefore the hospital. But if clinical observation can teach him to know the form and the course of diseases, it is insufficient to make him understand their nature; for this, he must penetrate into the intimacy of the body and seek which are the internal parts which are damaged in their functions. This is why the clinical observation of diseases was soon joined to their necropsy study and cadaveric dissections. Today, however, these various means are no longer sufficient; it is necessary to go further in the investigation and analysis of the elementary phenomena of organized body parts [...], the physico-chemical conditions that enter as necessary elements of vital, normal and pathological manifestations. » (Bernard, 1865/2013, p. 199). Such a re-hierarchy of values, which could be linked to the new values conveyed by industrial society, leads de facto to a weakening of the traditional figure of the clinician as well as that of the patient, and to the rise of laboratory protocols and the quantitative method, which is reshaping medicine, not without controversy (Latour, 1984 ; Demazeux, 2019). But this new perspective has yielded good results. Medicine - i.e., the medical clinic - is treating better now that it is benefiting from the contributions of experimental research.




Today, as a continuation of this historical movement indexed to efficiency, the traditional opposition even tends to be surpassed, beyond the respective conservative imaginations. Clinical thinking must integrate experimental thinking as much as possible. The paradigm of so-called "translational" medicine promoted since the 2000s by public health care institutions is an illustration of this (Ogilvie, Craig, Griffin et al., 2009 ; Weisz & Bearman, 2014). This new way of thinking in medicine, with a "bench-to-bedside" continuum of thought (Woolf, 2008), aims to implement experimental logic at the heart of the traditional relationship with the patient. From clinically oriented research in medicine, a research-oriented clinic has gradually been favored.




In the psychological field that interests us more particularly, a similar movement takes place, differently. From Lightmer Witmer to Lagache, via Freud, a psychology then called "clinical", developed in the field of patient encounters, distinguished itself from the oldest laboratory psychology. (Prévost, 1973 ; Forrester, 1996). One of its most explicit definitions can be found in the manifesto accompanying the first issue of the Journal of Clinical and Therapeutic Psychology (created by Hartenberg et Valentin). The term then refers to a psychology « clearly distinguishable from experimental psychology» (Prévost, 2003, p. 23) : « Experimental psychology isolates and dissociates the components of psychic life. It arouses, under prearranged conditions, the phenomena of sensation, volition, ideation noted and measured with the help of calculation and recording instruments. It leads to averages that are more satisfactory the more abstract and more general they are. It is, so to speak, the mathematics of psychology. […]. Clinical psychology, on the contrary, while drawing valuable information from laboratory research, observes psychological life itself, considered as a concrete and real whole. It brings together the natural and spontaneous reactions of the subject, in the presence of all kinds of excitement, in an overall view, to form a synthetic picture, with variable dominance, which expresses his temperament and bears the mark of his character. Through the combined influences of heredity and environment, it pursues the normal and pathological development of the personality, the task is not to schematize but to individualize. » (ibid., p. 23-24)

. Until the 1980s - and despite some attempts (Raimy, 1950; Frank, 1984; Baker & Benjamin, 2000) - observation and listening, typological reasoning based on singular cases, prevailed in research and practice. With the rise of evidence-based medicine in the 1990s (Eddy, 1990; Guyatt, 1992) and the related demand for empirically supported therapies (Chambless & Hollon, 1998), the experimental approach has, however, formulated the objective of restructuring classical clinical thought on the model of medicine - for example, by protocolizing and "manualizing" psychotherapies (Beck & Emery, 1977 ; Rosner, 2018) and in any case by seeking generic operating levers (and no longer on a case-by-case basis).



Since the years 1990-2000, in the United States, the different currents of experimental mind psychology (cognitive, behavioral, developmental, neuropsychology) have been claiming a more scientifically legitimate "clinicity" than that of traditional clinical psychology or psychoanalysis: the recent Delaware project is a strong example of this (Shoham, Rohrbaugh & Onken, 2014). Promoted by the National Institute of Mental Health in the United States, it completely redefines what it means to be a psychologist, i.e. to be a clinician whose "scientific training [...] will help to shape better outcomes" (Shoham, Rohrbaugh & Onken, 2013, p. 16), coupled with a "care manager".




The article by Gregory Simon and Evette Ludman It's time for disruptive innovation in psychotherapy is enlightening and illustrates the "new silhouette of the human being" outlined by scientific naturalism (Andler, 2016). Published in 2009 in The Lancet, one of the most prestigious international medical journals, it acknowledges the ongoing redefinition of the status of "clinical" psychologist, enjoining the use - in the name of clinical efficiency - of all available technical tools for decision support and computer assistance: « The success of computerized, Internet-based telephone actions - such as cognitive-behavioral call centers offering live chats from abroad, available as soon as patients want them - would horrify many traditional therapists... But therapists' expectations do not coincide with what the evidence allows us to anticipate.  And the evidence speaks rather of clinical and economic benefits for patients, rather than what therapists prefer to practice » (Simon & Ludman, 2009, p. 595).

In France more particularly, with the Inserm report and the succession of "good practice recommendations" from the HAS in different reports, the same trend has been at work for about fifteen years: to bring clinical thought and practice to submit to protocolized logics and procedures that have proven their effectiveness in the laboratory, in the name of efficiency (Leichsenring & Steinert, 2019 ; Woll & Schönbrodt, 2020 ; Gonon & Keller, 2020 ; Visentini, 2020 ; Rabeyron, 2021), although the added value of such experimentation in clinical thinking remains uncertain (Visentini, 2021).




Psychoanalysis is therefore caught between - or called upon to consider - two poles of demand: that of respecting the system of ordinary conversation ("Gesprach", to use Freud's word) by which it elaborates its own scientific tools (on the side of the human sciences, therefore); and that of subscribing to the imperatives of good practices, which promote, for each treatment plan, the best experimentally tested ones. It must therefore consider both its own epistemology and the clinical logic it promotes (abductive reasoning, comparative approach, etiological polyfactoriality, afterward logic, holism, emphasis on psychic uniqueness - and its links to general ascents -, leafing through its objects, analysis of the mechanisms of transfer and counter-transference, etc.) It must then translate the core principles back out onto the stage of the ethical and scientific debate, and - in a second step - submit them to comparative external evaluation.




The discussion is open: are experimental and formal logics electively relevant in the field of health care (in medicine as well as in psychology), or do other logics of thought have their place, more intimately related to the "natural" (and not artificial) grounds of practice? Can we admit, in psychoanalysis, the thesis of a necessary "logical hybridization" (Poenaru, 2018)? In psychology in particular, what alternative logics of thought exist to the many laboratory protocolizations? How to characterize them differentially? What place should be given to each of them? Which analogies and metaphors are relevant for thinking about psychic life, and which ones have limitations?



Our focus in this issue is on: contributions in the epistemology of medicine, psychology and psychoanalysis, preferably elaborated according to a comparative approach, and mobilizing interdisciplinarity; methodological contributions (what are the research possibilities for each of these disciplines in the field of care?); and problematic contributions, which question the concepts at their limits in order to determine their complexity and internal tensions, notably on the basis of examples from practice in the clinical field.

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