Caroline Goldman does not hide it: she is on a crusade to defend psychoanalysis. Throughout podcasts and interviews, the child shrink and eldest daughter of the favorite singer of the French explains how much this discipline carries her. If she denounces some excesses, it is to better point out the excessive weight, according to her, of scientific psychology and neuroscience in the care of children. But does psychoanalysis really need to be defended? And should it even be defended?
In 2021, a meta analysis showed that this approach could have some positive effects on anxiety or depressive disorders in children and adolescents. “However, we are still far from the solidity of the evidence obtained by behavioral and cognitive therapies”, notes Thomas Villemonteix, lecturer in psychology at the University of Paris-VIII. According to this expert, this work mainly focused on brief and structured psychodynamic care, common in Anglo-Saxon countries but quite far from French practices. “Psychoanalysis is a theory, an almost spiritual adult quest, and I understand that its theoretical aspect can be seductive, but when we confront this theory with clinical practice, especially in children who have difficulties, it is demonstrated that it is not effective, slice Nathalie Franc, child psychiatrist at the Montpellier University Hospital. She offers no diagnosis, no solution, apart from modeling clay and drawings”.
Some psychoanalysts, including Caroline Goldman, even suggest that attention deficit disorder with or without hyperactivity (ADHD) would be an invention of the pharmaceutical industry, to sell drugs like methylphenidate (a molecule better known as Ritalin). “This is a dangerous discourse, outside the scientific field”, warns Thomas Villemonteix.
A relationship under influence
Globally losing momentum abroad, psychoanalysis nevertheless remains very present in our country. “Its influence is declining, but many psychiatrists and child psychiatrists with psychoanalytic training continue to practice and the current debate around education shows that it has not disappeared”, underlines Héloïse Junier, psychologist and early childhood trainer. For those who doubt it, the latest report from the High Council for Family, Childhood and Aging (HCFEA) provides compelling proof of this influence. The authors of the document denounce the increase in the prescription of methylphenidate against attention deficit disorder with or without hyperactivity (ADHD), which they consider “not so effective”. Two questionable statements, since this product is still proportionally less used in France than in other countries, and various large-scale studies have shown its benefit on mood disorders or suicidal tendencies in patients. The report also cited psychotherapies, putting systemic, cognitive-behavioural (CBT) and psychodynamic approaches on the same level. The latter, of psychoanalytical inspiration, have in fact never demonstrated their effectiveness in neurodevelopmental disorders. Many early childhood professionals were moved by this publication, some seeing in it the influence of Sylviane Giampino, the president of the HCFEA, herself a psychoanalyst. Asked about this point by L’Express, the latter refused to comment.
On the ground, the associations of parents whose children suffer from autistic disorders, DYS or ADHD continue to denounce the support offered in the medical-psycho-pedagogical centers (CMPP) or the medical-psychological centers (CMP). “We still have far too many testimonials from families who fail to obtain a diagnosis, on whom family psychotherapy is imposed, or whose children are seen for years, without appropriate care”, deplores Nathalie Groh, president of the federation. French from the DYS. In the suburbs of Paris, Jana, mother of two boys suffering from ADHD, was confronted with these difficulties: “The CMPP made us waste a lot of time. I had to turn to a private doctor to get a diagnosis. Since then, my children take methylphenidate, and they are better. They have integrated into school and are doing well,” she says.
The guilt of mothers
The same observation is made in maternal and child health centres: “Taking care of children’s behavioral problems is their core business. But are they sufficiently trained in parenting skills and CBT education programs? It starts to open up, but there are still many psychoanalysts in these structures”, notes Frédérick Russet, doctor of psychology at the Montpellier University Hospital. For parents, the lack of diagnosis is a key problem, because it can then be very difficult to obtain the implementation of arrangements within schools. “The current controversies around personalities like Caroline Goldman are proving to be very harmful, because they reinforce certain teachers in their refusal to hear that our children do not deliberately have behavior problems”, regrets Christine Gétin, president of the Association Hypersupers ADHD. This mother of three children is not angry with psychoanalytical approaches which “refuse to consider that there may be abnormalities in brain functioning, and which attribute all the difficulties to the environment in the broad sense. And therefore to families, and to mothers in particular”.
To obtain adequate support, many parents therefore turn to the liberal sector. At least those who can afford it: “Between the child psychiatrist, the speech therapist, the occupational therapist or even the psychomotor therapist, the rest to be borne quickly becomes very high”, sighs Nathalie Groh. While certain structures are changing, no one today knows how many CMPs and CMPPs comply with the recommendations for good practice from the Haute Autorité de Santé, which highlight approaches taken from scientific psychology and CBTs. “Unfortunately, these recommendations are not legally enforceable,” sighs a specialist in the matter. The Regional Health Agencies (ARS) could encourage CMPPs and CMPs to modify their practices. “The problem is that these agencies have a very broad scope of responsibility and limited means. One priority drives out the other”, continues this expert.
Resistance to change
It must also be said that the task is complex. Michel Keisler, general manager of the APAJH Gironde and manager of the four CMPPs in this department, knows something about it. Six years ago, when he arrived at the head of the association, he got down to this transformation: “We decided in 2017 to create neurodevelopmental centers with specialized teams and expert professionals within the CMPPs. At the start, we faced strong internal opposition. The medical directors of the four centers made the choice to leave, as well as some of the staff. However, we deployed a substantial training plan, spread over four years “, he recalls. Since then, the proportion of children diagnosed with a neurodevelopmental disorder has increased from less than 10% to almost 50%. “The profiles of the children are the same. Simply, previously, the diagnoses were not made according to the recommendations of the HAS”, he assures.
Another obstacle to development: the difficulties in recruiting professionals trained in the methods recommended by the High Authority for Health. “Even if some universities are evolving, a lot of teaching in psychology or psychomotricity remains very oriented towards psychoanalysis. We can see this clearly through the trainees who apply to our associations: they are often unfamiliar with cognitive-behavioral therapies”, notes Isabelle Rolland, president of Autistes sans frontières. For her part, Dr Amandine Bussière, president of the CMPP federation, explains the lack of development by “insufficient resources”: “The CMPPs have benefited very little from the budgets allocated to autism plans, whereas we would have needs in training and recruitment”, she underlines, while insisting on the importance of “a diversity of approaches” within these structures.
The interministerial delegation for autism and neurodevelopmental disorders had, however, conducted an experiment, by financing training and the purchase of diagnostic tools for voluntary centres. A few hundred had participated, but resistance remains strong. Thus, in 2021, a dozen associations of psychologists challenged before the Council of State a ministerial decree which claimed to frame their practices in the brand new “advice and guidance platforms” opened to meet the needs of the families concerned. Their appeal was dismissed. This episode shows it: without a strong political will, the changes will continue at the current rate. Much too slowly.