The views expressed in this blog are those of Dr. Andrew Blewett, Consultant Psychiatrist, they are general and speculative opinions, not intended to refer to individuals I have known or worked with.

We currently face an extraordinary economic, political and cultural crisis in those countries conventionally known as the western democracies. This clearly applies as much as anywhere to the French republic, immersed in a morass of perceived or actual corruption in her political class, a seeming inability of the mainstream leadership to deal with pressing economic and social pressures and most dangerously of all the resurgent triumphalist right wing populism of Marine Le Pen. So what if any dilemmas of identity and direction linked to these profound existential dilemmas can be discerned within French psychiatry?

It should not be forgotten that the roots of modern European or “western” psychiatry are French. This is true on an institutional level expressed through the development of an enlightened hospital system in the aftermath of the Revolution. The venerable Salpetrière Hospital in Paris boasts an enormous canvass depicting the symbolic and revolutionary liberation of the “mad” by Philipe Pinel, still impressive for its optimistic radicalism. The intellectual and cultural renaissance in nineteenth century France also saw the emergence of modern descriptive psychopathology and the origins of modern diagnostic systems.

Significantly, the birth of psychoanalysis resulted from the experiences of a young Sigmund Freud in the same Salpêtrière Hospital in the 1880s following the work of the neurologist Jean-Martin Charcot on hysteria. Less well known outside specialist circles, the under-estimated psychology of Pierre Janet developed from the end of the nineteenth century anticipating much of modern cognitive behavioural theory and therapy. Unfortunately for this rich tradition, its reliance on French language and cultural expression has tended to obscure it in the blizzard of English language publication which has come to dominate psychiatry as the rest of medicine and science, especially in the period since the end of the second world war.

Within French psychiatry there is still a hankering after the vestiges of traditional diagnostic nomenclature, an engagement with the elaborate inverted pyramid of Freudian speculation in mainstream psychiatry and perhaps most interestingly a patchy resistance to the world of “evidence-based medicine”, so prominent in English speaking scientific literature. Is there a way forward for the French tradition which would not feel like a wholesale capitulation to the dreaded “anglo-saxons”, (a category which means more to French ears than to the supposed members of this tribe)? The reality is that the anglophone and U.S. dominated “DSM” diagnostic system, with its frequently arbitrary cook-book diagnoses well suited to the private insurance industry and the concept of evidence-based theory and practice have achieved a remarkable global pre-eminence, whether or not this is perceived as a good thing. Why not go with the flow?

It may seem bizarre to anyone outside of medicine that its practice should be anything other then evidence-based, but in reality 'evidence' is complex and freighted, not least because there are numerous assumptions about outcome and benefit which have to be addressed sometimes in quite non-scientific terms. Further, the ownership and use of evidence can appear political or commercial, despite the goal of scientific integrity. These difficulties leave plenty of scope for expanding and developing the discussion in ways which were not envisaged by the highly reductionist originators of the concept. The importance of patient (and clinician) experience and the necessity of qualitative methods in making sense of the science on a human level might just be an open door for the traditional French psychiatric imagination not averse to expansive reasoning and disdainful of earthy anglophone empiricism.

So, a new sort of evidence, less linear, more subjective, bearing witness to the daringly ambitious and the frankly uncertain, might just offer the space that French thought has traditionally been willing to explore. The day of the grand experiential narrative monograph may not be over. It is quite clear that a re-invention of “evidence” à la francaise, alongside the kind that we have come to expect, is entirely in order…

See link DSM et EBM : un débat dans la revue Psy Cause - PsyCause: en ...

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