11 de fevereiro de 2008

Paris Calling - arguments against evidence based practice by E. Laurent

The London Society of the New Lacanian School

Dear Colleagues,

Attached you’ll find a paper by Eric Laurent given at the ‘Depression’ conference held in Paris recently. The arguments against the wisdom of evidence based practice are invaluable tools for us here in Britain.

Kind Regards
Natalie Wulfing

Paris Calling No. 6b

As was mentioned in the report published in Paris Calling No. 6, during the 2 February afternoon session of the Déprime-Dépression Colloquium dedicated to ‘Depression, Politics, Psychoanalysis’, Éric Laurent took the floor to present ‘a six-point breakdown of the perverse effects of the evaluation system on clinical practice’. Éric Laurent has kindly sent us the text of his intervention which we are publishing below in English translation.


The Perverse Effects of EBM and the Remedies that Psychoanalysis Brings
Éric Laurent

1. The Perverse Effects
Standards of healthcare services now like to be defined on the basis of statistical evidence. This is the standard proper to the era of Evidence Based Medicine (EBM).
Favouring evidence obtained by statistical correlations of homogenous patient samples produces a certain number of perverse effects on clinical practice. They can be grouped under six points.
a) Incommensurability between characteristics of the sample and the precise subject in treatment.
b) A preferential bias for straightforward treatments limited to one individual intervention, to the detriment of complex treatments with psycho-social and subjective aspects that are hard to measure.
c) Exclusion of clinical savoir-faire.
d) Production of protocols that are becoming widespread and limit choice or necessitate uncontrolled ad-hoc adaptations.
e) Inability to take into account the points of view and the values of suffering subjects.
f) Production of a bureaucracy dedicated solely to measuring the distribution of the protocols.

These perverse effects can be seen throughout the healthcare system. They are exacerbated in the field of mental healthcare. Mental suffering is not the suffering of the brain, it is the suffering of a body which alters the ‘kernel of our being’ to use Freud’s expression. It alters our deepest capacity to be able to translate the ‘movement, the infinity of life’ in us, as Georges Canguilhem put it, particularly within the different aspects of depression. Its polymorphous character and the polymorphism of the treatments that are applied to it, such as this colloquium will be tackling them, highlight in particular the limitations of the protocols.

2. The Remedies that Psychoanalysis Brings
The prescription of a psychotherapy, which is often recommended, is too vague for taking into account the particularity of the subject’s suffering. There is no unity of psychotherapy. Let’s distinguish between those psychotherapies that authorise themselves based on measures copied from random clinical trials, the EBM method par excellence, and those that authorise themselves based on symbolic efficacy.
The psychotherapies that authorise themselves based on EBM methods come up against the same limitations as their models. It is all much of a muchness. As for psychoanalysis, it authorises itself on the basis of a different efficacy, one that it gives an account of through qualitative methods founded on the clinical method of the ‘case by case’. For each of the six limitation points of EBM, it inverts the thrust of the evidence.
a) It starts off with the subjectivity of the sufferer and not with the sample.
b) It privileges complex methods and not straightforward medicinal intervention on the individual’s body.
c) It integrates clinical savoir-faire.
d) It is wary of protocols and standards.
e) It finds in what the subject says and the values he has the very material of its action.
f) There is no bureaucracy to measure uniformalisation.

The difficulty in specifying the modalities of introducing psychoanalysis into healthcare systems is due to having only considered the modalities of its traditional private practice. However, the application of psychoanalysis to diverse modalities of the healthcare system goes back to Freud himself. This application has never stopped being renewed.
Over the last years, it has taken the form of Centres for Psychoanalytic Consultation, flexible intermediary structures that are open and non-profit making. The treatment mode is based on free consultation with psychoanalysts, on a weekly basis, for four months (sixteen sessions) that may be repeated a second time. The results presented to the administrations that fund them have been encouraging. The centres are starting to spread in France, across Europe, and in Latin America. This is why we may consider a mode of contractual association with this kind of institution within the healthcare system.

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