Courtil : a choice
Two years ago, along with a few colleagues from the Ecole and the ACF Belgium1, we decided to found within the framework of Courtil an institution destined to receive twenty-five young adults suffering psychosis or acute neurosis. It wouldn't be about emergency psychiatry, nor hospitalization, but rather the reception of vagrant youth or those who risk aggravation of their cases in the psychiatric hospital. We called it "Courtil - Center for Adults," although the age of the residents there ranges from seventeen to twenty-two, thus including older adolescents.
I want to start by recapitulating the history of Courtil from its beginnings: in other words, its work with children. The Center for Adults is founded on a clinic and a pre-existing work with children. As I will emphasize, we have never thought that there was a psychoanalytic clinic specific to children, even if there are modalities of the practice which distinguish psychoanalysis and psychoanalysis with children. The principles studied at the Center for Adults thus remain in continuity with those of Courtil.
Courtil : a history
Courtil already had twelve years of experience with psychotic and acutely neurotic children. Founded in Belgium, but in the suburbs of the greater Lille-Roubaix-Tourcoing agglomeration, it received in the beginning twenty children and young adolescents. It progressively grew and burst its structure. Today it receives around eighty young people. Two years ago, we also opened, besides this structure for young adults, a Courtil for more socialized children -- which is to say, those enrolled in school.
« Courtil » is the name given, in old French, to a courtyard or interior garden, which well characterizes the first place where we had commenced our work. « Often employed in the old tongue, this word is now hardly used except in the country, under very diverse forms. »2 In the beginning, Courtil very modestly only received a few autistic and moderately retarded children. Quickly, its clinic was rather oriented toward young psychotics who spoke, schizophrenics at first, followed by young adolescent paranoiacs.
The founding of Courtil, first for young children and a few adolescents, was inscribed in a series of encounters: encounter with the psychoanalytic clinic and its irreducibility to the most current psychiatric clinic, encounter with the teachings of Freud and Lacan, encounter with the texts of psychoanalysts working in institutions in the sixties (Bettelheim, Oury, Maud Mannoni), encounter with Antonio di Ciaccia who founded an institution for children in Brussels, the Antenna 110, whose reference was also Freudian and Lacanian.
The clinic of the child
If the psychiatric clinic of the adult has a long, classical history, the psychiatric clinic of the child and adolescent is recent since it is almost entirely posterior to the Freudian discovery of the unconscious. Before the twentieth century, the « mentally disturbed » child had been evaluated solely along the lines of quantitative criteria establishing retardation. Of course, there is the famous case of Victor of Aveyron, who presented a sort of experimental, involuntary autism, but then the question was, above all for Itard, to develop a pedagogical method rather than draw conclusions for a truly classical, psychiatric clinic of the child. Of course, at the turn of the century, there were the texts of Moreau of Tours, but his interest was only academic.
The clinic of the child begins with Freud and after Freud. But it began in a curious way. Freud was never interested in the child per se, except in setting out from the adult. With the case of Little Hans, it was for him less an introduction into the possibility of psychoanalysis with children than to demonstrate the pertinence of his theories of the infantile among adults. And the case of the Wolf Man remains the major demonstration of the existence of infantile neurosis as presiding over the pathology of the adult.
Beyond the passage from the theory of infantile traumatism to the theory of the phantasm, implying a part of the real inassimilable to any speech, Freud discovered that this part was due to infantile sexuality before and beyond the genital sexuality supposed to the normal adult. It is this infantile, woven of conflicts, which organizes neurosis. And from then on, one can consider that the aim of the analytic cure would be to find again this infantile in the subject.
Can the aim of psychoanalysis of the child be different – even if its thrusts are particular ? With the child, is one closer to this infantile knot at the heart of the subject ? Anna Freud had supposed this true, with her pedagogical deviation of psychoanalysis. But it is also what Melanie Klein produced, supposing that the unconscious is structured like a phantasm. And this didn't escape Francoise Dolto when she wrote a book on the JJ« prevention of neurosis ».
Freud, reread through Lacan, implies rather finding again the adult in the child, which is to say, already submitted to the conflicts that infantile sexuality has made emerge for him. And if the cure is sometimes more rapid, this however isn't obtained by shorter paths than with an adult; desire has its reasons that only the reason of the unconscious knows without knowing it.
The institution and the ideal
What is the most marked in the debate over psychoanalysis with children in institutions in the sixties and seventies is the very idealization of institutional work. Yet, it must be noted that from psychoanalysis' point of view there isn't an institutional ideal, but rather that each and every institution functions out of one or more identificatory traits which characterize it. These traits can always lend themselves to the constitution of an ideal when they are given a universalizing value for all those who participate in this institution. Because of this, every institution is structurally opposed to the place the analyst takes when he accords full value to the particular in a subject's discourse.
One can hold that a child is always in an institution, an adult as well for that matter: the army or the church, the family or a health care institution, and still others3. And when a youth finds himself in the street, it also is an institution with its organization (gangs for example), its hierarchies and even the political discourse that accompanies it.
Certainly, not all institutions are meritorious. We know how Freud developed, in IIThe Psychology of Masses and the Analysis of the Ego, with the structure of hypnosis, the case in which the ideal (I) and the object Ia are confused in their articulation with the figure of a leader. This case, as we have known since then, can be the support and cause of the worst horrors. There are other institutions which attempt to maintain a certain gap in this structure, a certain regulation of the relation of each one to the ideal, such as the figure of the enlightened master, or the democratic forms of modern institutions. In our psychoanalytic schools, this is the function of the rotation of directors, the democratic vote and sometimes the drawing of lots.
But whatever the distance set up around the figure of the leader, and the modulations of enlightened master, it remains that psychoanalysis subverts the relations that the subject entertains with his ideals. While the structure of the institution promotes a universal value, valid for all, the analytic ethic puts forward the value of the particular, the most singular case. Certainly, the institution can change its values over time, but it cannot change the universalizing aim of the value it gives itself.
One possible response to this paradox is that which Freud gave us in the beginning: the dissolution that he foresaw as automatic. And it is this response that Lacan utilized when it was necessary. And one sees this again in the Ecole de la Cause Freudienne, which modifies its function when this no longer works efficiently in the direction in which it was founded. It takes a very clear stand: psychoanalysis first, the institution when it serves – and thus dissolution or modification of the institution when it no longer serves its objective. An adherence to the institution remains, that we have seen at work during the dissolution, in the resistances put up by a certain number of people against losing the comfortable universality of the instituted, at the risk of losing sight of the object that founds the institution.
But this response is hard to apply to health care institutions in which psychoanalysts work. In another text, I developed certain problems with this paradox and the necessity, in responding to it, to bind intension and extension in what Lacan called "applied psychoanalysis," which is to say, the « therapeutic and [the] medical clinic. »4 From then on, the paradox remains whole and without solution. The health care institution for children or adults called « mentally disturbed » generally has for its goal the cure, or an amelioration, or the future good of the patient. There are non negligible values toward which we work. But the universal character given to these values is in disagreement with the analytic discourse which, certainly, obtains a cure – if one means by that the therapeutic effect – but without aiming for it and above all without knowing SSa priori what this will be, preferring rather the JJSwhat it will have been.
In addition, these health care institutions inevitably function with a certain number of « specialists » (special ed. teachers, doctors, psychologists, orthophonists, physiotherapists, etc.), to wit, in a certain pluridisciplinary approach – so-called rapid therapy, family therapy, neurolyptics, etc. We haven't time to critic the modalities of organization, but it must be noted that none of these places is suitable for the psychoanalyst. If the psychoanalyst wants to operate in an health care institution, this can only be out-side any position of specialist in psychoanalysis among the other specialists.
There is the ideal of the institution (I), and there are the traits identifying each specialist (I). Before these ideals, shared universalities made common through « synthesis » meetings, if one wants to be analyst, one can only place oneself there along a certain bias, a certain lack IIa. To the general case of the specialists, one must respond with the particular case. To the universal aim of the institution, one must respond with the singularity of the patient's discourse. In other words, even within, one must be outside. It is the condition for a possible cure in institution when this is possible.
Courtil : a choice
Courtil's choice, first of all, is not that of introducing the analytic cure in institution. The experience we have attempted aims rather at knowing if it is possible to lodge the analytic discourse in the heart of the institution, which is to say, subvert the institution through psychoanalysis. In the cure, the psychoanalyst must represent an unknown desire for the analysand. This makes it difficult for him to be identified as one specialist among the others. But can he introduce this unknown element into the heart of the institution ? Can one introduce the function of psychoanalysis there, where a normalizing ideal figures ? Certainly not by placing psychoanalysis as a therapeutic ideal in the place of the institutional ideal, whatever it might be, because psychoanalysis would lose its very aim of putting the ideal in question. But it is perhaps possible for psychoanalysts to introduce this function of unknown desire in place of the normalizing ideal of the institution. In other words, the institution becomes particular and different for each youth.
The analytic cure is not practiced at Courtil. It is a choice made from the beginning, the foundation of Courtil. We wished in this choice to avoid a double pitfall: that of the psychoanalyst specialist that we examined above, and that of the institution as waiting room for the psychoanalyst, which is the case of nobody worrying about the work carried out by the educators in the field, but where the children are regularly sent to the psychoanalyst for therapy. This second pitfall is not necessarily opposed to the presence of analytic discourse, except when the cure appears as « indicated », in the sense that work with a specialist is indicated as necessary. However, we wish to avoid it. In addition, the choice to situate the analytic cure, when it might be requested, outside the institution and at the analyst's office appears to us more rigorous.
A certain number of consequences logically flow from this: to accord importance to the training of the team, to formalize our work in the study of clinical cases taken one by one, to eliminate the distinction between teachers and specialists, to reflect on the function of management in an institution that has been subverted in this way, to organize the work with patients so as to privilege the effects of speech, to support not accepting the IIa priori of distributive justice.
Courtil's Center for Adults
After having founded Courtil as an institution for children and young adolescents, we wanted to test our experience in a clinic for young adults. None of the founding principles seemed to us to need modification.
But before returning to these, some practical elements of our clinic must be specified. We situate our work in a clinic that is neither emergency, nor chronic. The stays at Courtil, for the children, last on the average less than two years, and up to a maximum of four years. At Courtil Center for Adults, we have chosen to limit the stays to a maximum of three years, but the average stay currently doesn't exceed one year. Furthermore, the three institutions using the signifier « Courtil » – the Extensions and Day Center, the Apartments for children in school and the Center for Adults – function on the same founding principles, with lots of exchanges between them concerning the formalization of clinical cases. However, few youth pass from one Courtil to another. This means that the young adults received at the Courtil Center for Adults come much less often from Courtil for Children than from the psychiatric hospitals of the region. The largest part of our young adult patients are psychotic, schizophrenic or young paranoiacs, with a few rare neuroses. It is a particular clinic which has its limits: thus we do not admit young addicts nor serious delinquents.
The formalization of our clinical practice occupies a large place in the work of Courtil. The clinical meetings are not « synthesis meetings » between different « specialist's » points of view (special ed. teachers, psychiatrist, psychologist, social workers, etc.) who believe they have to make a decision on the case, without worrying about whether or not such a decision isn't just passing to the act. The clinical meetings serve rather to construct the cases, one by one, in a psychoanalytic clinic. This construction allows us to deduce the orientation the work has taken and which decision to make. Formalization implies transmission and pushed us to found our review, IILes Feuillets du Courtil5, to testify to this elaboration. It is also the reason behind our special care in training the team: there are no specialists in clinical work, each one can know if he/she wants. This is not to say that there is no hierarchy, or there aren't any specific positions at Courtil. On the contrary, there is a management that seeks to clearly orient its work6. For us, it is rather a question of trying to put to work a distinction between hierarchy (direction and specific positions) and grade (participation in clinical training).
But then, when we say that there isn't any specialist in the clinical intervention, does that mean that there are only psychoanalysts working on the terrain ? Certainly not! We might even say, in the strictest sense, that there are no psychoanalysts instituted as such in the institution since we do not IIa priori arrange for psychoanalytic cures there. What's more : the intervenants do not have to sustain the position of the analyst in the strictest sense in the analytic discourse (IIa/S2), along with all that this implies of the presence of the desire of the analyst IIa and the interpretation in the position of truth (S2). There are two reasons for this : most of the intervenants are not psychoanalysts, but analysands – they are in analysis or have been – and the majority of the residents are psychotics, implying, in any case, another aim in our work. Rather, we expect of the intervenants that they be situated as « civilized analysands »7, meaning that each one is at work on analysis and enlightened in his orientations by the analytic doctrine.
When a new resident arrives at the Center, we announce to him two rules: violence is forbidden, and he is under obligation to meet once a week with a « referent ». By this we wish to put the accent on a possible work of elaboration through speech. We do not expect this work to take place exclusively with the referent, but I would say rather that the function of this « referent » (a consultant which most often isn't from the Center for Adults team) is to represent our desire that the subject go to work : elaborating his delusion, reconstructing his history, developing the causalities of his symptom, requesting, etc. The work with the patients – or residents – aims at privileging the effects of speech and the subject's locating these effects. However, this must be articulated differently according to whether the resident is psychotic or neurotic. This already says something about the importance we give to the diagnosis in the first period of the clinical case formulation.
One might object that our reflection on what founds Courtil is essentially oriented on concepts that are useful in neurosis while the majority of our residents are psychotics. Note however that the clinic and the doctrine of psychoanalysis are themselves founded by Freud on the encounter with neurosis. These are the Freudian and Lacanian concepts we use. They are pertinent to neurosis. But they are also pertinent to psychosis, on condition that the practice be adapted to the conditions and exigencies of that structure, which modifies the aim of the work.
With a neurotic, we attempt to operate a reversal of the position the subject occupies in his complaint ; what Lacan called, in « The direction of the cure », a « rectification of the subject's relations to the real ». It is a preliminary period in the cure in which the subject appears as responsible, having to answer for that about which he complains. From then on, our aim is to make possible a request for analysis, beyond the work done in institution8.
With a psychotic, on the contrary, we will operate, according to the possibilities of the subject's structure, to permit the elaboration of a delusion (on the paranoid side)9 or the constitution of some partial, imaginary ego (on the schizophrenic side. The institution fills-in sometimes for the lack of underpinnings.
1Phillipe Bouillot, Dominique Holvoet, Katty Langelez, Anne Lysy-Stevens and Bernard Seynhaeve.
2Dictionnaire des dictionnaires, second edition.
3This is Eric Laurent's position in « Institution of the Phantasm, Phantasms of the Institution »
4Stevens, Alexandre, « Applied Psychoanalysis »
5One will find in the series of the fifteen issues of Les Feuillets du Courtil already published numerous clinical studies that question our way of approaching our work. [Many of these articles make up The Courtil Papers. trans. note]
6See the articles by Bernard Seynhaeve, « Au depart le transfert...ou l'admission des enfants dans une institution specialisee », in La lettre mensuelle, n°108, pp. 23 - 26 and « Le discours du maitre, qu'en faire ? », Les Feuillets du Courtil, 8-9, pp. 145 - 149.
7After the expression Eric Laurent proposed to one among us to qualify our work.
8Stevens. A., « La clinique psychanalytique dans une institution d'enfants », in Les Feuillets du Courtil, n°1, pp. 37-43.
9As one sees in the article by Philippe Bouillot, the institution, its structure and even its walls fill in for the difficulties of the organization of a delusion.