I'm going to talk to you about treating psychosis with psychoanalysis.
In 1982, we opened the Center for psychoanalytic treatment of young adult psychotics in Quebec,
which is referred to by its street address, "388", to keep the anonymity of the Center.
What is psychosis?
Also known as schizophrenia, psychosis is a severe mental illness
that can have devastating effects.
Symptoms include delusions, hearing voices, unbearable anguish;
Patients will also be mistrusting, or closed off in an imaginary world.
They will suffer from severe, sometimes extreme psychological distress,
will cut themselves off from other people, and live in solitude.
In the early 1980s, psychiatric science was at an impasse with treating psychotics.
Treatment at the time consisted of medication and hospitalization.
But medication couldn't prevent relapses;
so patients would be re-hospitalized more frequently and for longer periods of time.
As result, symptoms became chronic.
This was known as the "Revolving door syndrome",
whereby patients spent more and more time at the hospital,
were increasingly marginalized,
and placed in health care facilities, often for life.
Today, in 2012, not much has changed.
Nevertheless, there has been an important one:
the chemical dimension of treatment has been strengthened.
According to psychiatric biology, psychosis is a brain illness
So the psychiatrist, who is also a doctor,
will treat the sick brain before taking care of the person in distress.
Thoguh it is well known that medication today can alleviate symptoms,
they still can cannot prevent relapses from happening.
In 1980, when the 388 was first opened,
psychotic patients were also at an impasse with traditional psychiatric medicine.
They felt ignored,
they were afraid of speaking up,
afraid of talking about what they were going through.
When they did talk, they were told they were insane, delirious
that what they said wasn't real and they should forget the imaginary voices.
"Ignore the voices".
Then patients were given more medication and kept at the hospital for longer
until they eventually became quiet, and removed from others.
One of the patients talks about this impasse.
"I lost my friends... I wasn't feeling well.
I was going crazy, I could hear voices,
and I always carried a knife with me.
I couldn't take it anymore... I wanted to end my own life.
I went to see a psychiatrist
but he didn't ask me what was wrong-- I didn't get a chance to talk.
I asked for some psychotherapy, but he said it really wasn't for me.
I started taking pills, and then the medication stopped having an effect on me
or on the voices; and on top of that, I was gaining weight.
It went on like this for years, until the doctors found a miracle medicine.
I felt better for 6 months, even got a job...
...and then I had a major psychotic attack at work
-- even though I had been taking my medication.
I called my psychiatrist and told him that my medication wasn't working;
all he did was increase my dosage.
I felt like my life was over.
I had no purpose, I fell into a deep depression,
I wasn't doing anything anymore, not even speaking."
Another patient, Mr. F, talks about his isolation:
"I feel gentleness,
I feel sadness,
and I am alone.
Life is like a hard lump stuck in my throat."
30 years ago, GIFRIC psychoanalysts and psychiatrists
were already trying to find alternative ways of treating psychotics.
They wanted to give a future to those psychiatry had left out in the cold
by offering them a real and dynamic treatment
in which they would no longer be passive spectators of their own treatment,
as they had been in traditional psychiatry.
GIFRIC psychoanalysts wanted to offer an alternative to treatment and hospitalization,
to offer a choice of treatment.
The alternative was founded on 3 A's:
(A)nother place, (A)nother way, (A)longside
I'll explain:
1. To find another place in the city, other than psychiatric hospitals,
and bring psychotics together in their own space
as a way of countering their marginalization in society.
2. To find a different kind of treatment, using psychoanalysis:
allowing us to hear and understand what psychotic patients have to say,
and encourage patients to speak about that lump in their throat
so that they can get things off their chest.
3. To treat alongside psychotic patients,
as a partner and main actor of their treatment in their treatment team;
to help patients fulfill their dream of being in control of their future,
of changing their own lives,
and to claim the spot in society that is rightfully theirs.
It was a challenge to do all of this in 1982-- and it is still a challenge today.
Opening the 388 center was an innovation in psychosis treatment.
Let me go back to Mr.D, the first patient, who said "I wasn't even speaking"
"I saw an article on the 388 center and figured, why not?
I started my analytic treatment. It was not easy and took a lot of hard work.
But now, I'm back in school, I talk, and I've got a new lease on life."
At the center for psychoanalytic treatment, psychoanalysis is defined as
"a set of ethical practices that will promote a space in social relationships
for unconscious desires."
This new type of psychoanalysis is open to the problems faced by psychotics,
and was made possible by the work of Willy Apollon, a psychoanalyst.
The center is located in a beautiful house in a bustling neighbourhood
in the heart of the of Quebec city.
The facilities are open 24 hours a day, all year round
There is no medication on the premises,
there are no isolation rooms or restraints;
The center runs on verbal agreements.
Elise says: "What I like about the 388 is that the house promotes social living,
that does not marginalize us."
The Center was born out of a partnership between an NPO, the GIFRIC,
and a public care institution-- currently, the CSSS Vieille Capitale.
The budget for the Center was made available by the
Ministère de la sante des services sociaux.
A complete psychiatric treatment is the first of the treatments offered at the Center,
performed by an interdisciplinary team trained in the psychoanalytical treatment.
This team, that is ready for anything, is headed by a psychiatrist-psychanalyst.
There are beds for treating those crises that used to send patients to the hospital.
Having these beds on-site avoids hospitalization.
There are also art workshops-- not art-therapy,
but workshops with real artists, musicians, ceramists, stage actors,
and painters
-- to allow psychotics to invent adequate means of expressing what words can't.
There are always things that cannot be expressed in words.
The Center also houses sociocultural activities:
these are group activities that break isolation
and favour the creation of strong relationships with others
through work and study projects.
At the heart of all this are regular, personal sessions with a psychoanalyst.
Through psychoanalysis, psychotic patients work on "the thing inside them"
-- or "the monster", in their words-- that makes their life unbearable.
Patients are guided through their suffering,
and go through why their life is insane in their eyes, and in other's eyes.
Patients talk about anything with their psychoanalysts;
but they talk about their crises in particular: the voices, the delusions, the dreams,
the inner demons...
They talk about the traumatic experiences in their life
and will try to make sense of all of it.
Then, patients try to find another way of living with others
so that they can give new meaning to their life.
The goal is to understand what happened to them,
to profoundly change their life.
One patient explains:
"I understood that psychosis is a language;
one that I would be the one to decode,
so that I would be able to never use it again."
Another patient shares his experience with psychoanalysis:
"In my treatment, the long process of de-possession was difficult:
breaking free of the psychological jail that confined me to exclusion.
Today, I no longer carry the weight of the voices of others like me.
In order to do that, I had to find the root of a fissure in my childhood;
and when I found that fissure, I could not just plug it up.
Now, my work requires that I do something that was completely unknown to me before:
Negotiating.
You cannot imagine how much human wealth negotiation represents."
At the 388, we have results
Here is some objective data from the GIFRIC clinical observatory
First, we have a significant decline in the number of hospitalizations
90% less hospitalization days for a group of patients
that had been in treatment for at least 3 years in January 2012.
This represents a substantial amount of cost savings.
The amount of medication was also reduced,
and the quality of life was also improved:
life in an apartment room, studies, work, friends
an independant lifestyle...
and being able to laugh again.
Psychotics go from being socially excluded to being full-fledged citizens.
They, like you and I, even pay taxes
There are 2 types of subjective data for the results
(1) Those taken from evaluations conducted in 2002 by Ministry of Health experts
In their report, they took an interest in parents
who saw their children become more open and express their personality.
They did this by progressively going through the stages of social reintegration.
The experts also noted that parents particularly appreciated how
treatment at the 388 allowed patients to optimize their abilities
and reach a state of recovery their families had stopped hoping for.
The second type of results are more important to us.
(Here's a picture of the green staircase)
What we care most about, is when the psychotics are discharged
Its who we care about most-- those whose lives were saved by psychoanalysis.
One such patient says:
"I used to deal to the difficulties I faced in life
by locking myself up in my imagination.
Sometimes it became nightmarish:
nobody wanted to hear about what I had in my soul.
My analytical treatment saved me.
The analyst accompanied me, without judgement,
through the meanders of my thoughts.
Now, I can face the challenges life throws at me
with the experience I amassed during my treatment."
Now I will conclude.
A couple years ago, after a visit at the 388,
a fellow psychiatrist-- a former director of a psychiatrist hospital in Montreal
as well as Canadian representative to the WHO at the time--
wrote the following:
"If the 388 did not exist,
it would need to be invented."