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Werken in een poel van angst en onmacht. Naar een herstel van de hulpverlener.

Psychiatrie wordt gekenmerkt door veel dwang en de herstelbeweging krijgt weinig vaste grond in de dagelijkse praktijken. In dit artikel probeert de auteur te begrijpen waarom. Hulpverleners geven aan dat ze angst en onmacht ervaren in confrontatie met psychisch lijden en dwang. Vanuit een lacaniaanse invalshoek kunnen we angst begrijpen als een signaal van het reële. Omdat psychiatrie werkt met hetgeen weerstand biedt tegen de heersende vertogen, zal het reële daar buitensporig aanwezig zijn. Psychiatrie wordt verwacht om het reële te genezen, dit geeft hulpverleners een macht die soms overweldigend en beangstigend kan zijn. De structurele onmogelijkheid om het reële te genezen zorgt bovendien voor onmacht. Manifestaties van het reële van patiënten komen in de overdracht en dat zorgt voor een confrontatie met het eigen reële. Daarom is er een structurele psychiatrische doodsdrift die altijd in het werk aanwezig is. Doorgedreven professionalisering, dwang en uitsluiting zijn manieren om die doodsdrift te ontkennen en te versluieren. Psychiatrie zou een discipline moeten zijn die nadenkt over het reële en probeert te conceptualiseren, in plaats van weg te moffelen. Om dit te doen, hebben we een herstel van de hulpverlener nodig.

Violence and aggression: a lacanian perspective

Although psychiatry often has to work with aggressive patients, the huge amount of coercion and exclusion based on aggression, teaches us that psychiatry does not know how to handle violence. In 1948 Lacan wrote an essay on aggressiveness, trying to approach the phenomenon within a structural framework, albeit without the conceptual tools to work this through. His later work, notably the differentiations between the imaginary, the symbolic and the real, helps us to read aggression in a structural fashion, taking anxiety at the core of the problem. The author wants to expand this by making a differentiation between implicated violence and non-implicated violence. The former is about the aggression as we usually understand it: between subjects, with the feeling one is implicated in it and grounded in anxiety. The latter is carried out as a collective, grounded within discourse that veils anxiety. This violence is essentially dehumanizing for both victims and perpetrators. One is violent because it ‘needs to be done’, justifying its action through discourse. The author explains how in clinical practice, we should read the violence of mental health workers (like coercion or exclusion) and its accompanying anxiety, rather than simply denouncing it. If not, we risk that implicated violence will alter to non- implicated violence, making it even harder to tackle. The author concludes with an example of her own clinical practice and analysis.

Psychoanalysis: a symptomatic problem

In this article the author explores why psychoanalysts are often seen as troublesome people and why they give so much critique. Foucault stated that in modernity the epistèmè changed: ‘man’ came in the thinking frame and human sciences were born. In his opinion psychoanalysis has in this epistèmè the position of a counter-science. In this article the author shows how psychoanalysis is different from human sciences in two aspects. First, psychoanalysis has another subject theory. The subject is not seen as something that can be discovered and has authentic qualities, but is fundamentally desiring and divided. Second, the author explains the difference in the way knowledge is grasped in psychoanalysis and human sciences by using Lacans discourse theory. These different points of view, mark the position of psychoanalysis in the modern epistèmè. The author concludes by stating that this is why psychoanalysis is so problematic for others. As a discourse, she is a symptom that appears because human sciences fail to grasp subjectivity. This is why psychoanalysis is fundamentally intertwined with the other human sciences and will probably disappear one day.

Humane Psychiatric Care in De Meander: A Matter of Ethics

This article describes a number of concrete initiatives taken in the De Meander in Melle (near Ghent, Belgium), a psychiatric ward for patients with a mental disability or an acquired brain injury, with the aim of introducing and safeguarding a psychoanalytic ethic. In the latter, the particularity of the patient plays a central role. De Meander tried to achieve this by abolishing many of the ward rules, allowing more space for the singular solution of the patient. Furthermore, the author describes how aggression is addressed differently, in order to learn how to read this rather than punish it. From an ethical perspective, the values and standards of mainstream society are no longer strictly adhered to, but the starting point is the suffering and the questioning of the patient as a unique subject. The author describes how patients of De Meander are given more responsibility for their lives and future. Hierarchical positions are lifted by creating the possibility of circulation between different team members and by using the therapeutic potential of patients. Finally, the author describes how, via volunteer work, an opening to the outside world is created for so-called chronic patients. These various concrete initiatives are illustrated using clinical vignettes.