The 388

For more than 30 years, the “388” has been a haven for people struggling with psychosis. A humble Victorian-Era house sitting amidst a bustling neighbourhood of Quebec City (Canada), this unique clinic is dedicated to providing an integrated, psychoanalytically-informed treatment of psychosis to willing users. Now considered by patients and families alike as a pillar of community treatment, it is still today one of the few places where patients can be “ accepted as are, for what may become. ”

Since it opened in 1982, the main goal of the “388” has been to deliver an alternative, yet state-of-the-art, therapeutic approach to young people suffering from schizophrenia or related disorders. How did the “388” achieve this? First and foremost, its founders began by challenging the longstanding assumption that psychosis cannot be treated with psychoanalysis. In order to allow psychotherapeutic work with psychosis, they had to create a new theoretical framework, which was based on their previous clinical experience with patients as well as on Freudian and Lacanian psychoanalytic therapy. The specifics of how they managed to integrate this clinical experience with psychoanalysis is beyond the scope of this article, but is detailed in numerous publications (see the references below for details). This theoretical stance is fundamental to the centre, as it informs the perspective of the whole team and thus provides a common understanding of the problems encountered by users.

“In the end, the most fundamental thing that psychoanalysis has brought to me is the freedom to stop destroying, and the freedom to start constructing.”
However, patients are not required to undertake a psychoanalytic therapy in order to start attending the centre. Psychoanalysis is indeed the cornerstone of treatment, so all users will be invited to engage in psychoanalytic work at some point. Still, psychoanalysis is only one part of a holistic approach including regular psychiatric follow-up, patient and family support by a team of mental health workers, art workshops with professional artists (engaged in music, visual arts, writing, drama, ceramics, etc.) from Quebec City, and many community-based activities (such as cultural activities, sports, etc.) that promote social integration. Users can also get involved in collective projects such as participating in biannual camp stays or by organising trips (for example, in 2016, some users self-funded a trip to New York City).

“What is mental illness? It is a feeling of exclusion. That’s my problem: I feel excluded.”

Group integration is a crucial part of helping patients: from a psychoanalytic standpoint, one of the main aspects of psychosis is that it loosens the bond between subjective experience and social reality. As social reality is, at least in part, collectively constructed and reinforced, people with psychosis may tend to become isolated and excluded from their communities. Furthermore, because this social space becomes persecutory, they might not understand how they could manage to give a voice to their own aspirations inside it. Hence, the “388’s” structure is entirely oriented towards promoting the reinsertion of psychotic individuals into the social link. What makes this “reinsertion” different from traditional social recovery therapies, though, is that it aims to support patients in their attempts to take part in social life, without giving up on their inner desires and aspirations. This orientation is directly drawn from psychoanalysis: the aim is not to extinguish one’s quest, but to promote it, and to articulate it within a group or society. It is for this reason that the spatial layout of the clinic is itself designed to promote integration: users can socialize in common living rooms, are invited to cook together, to share meals and so on. In terms of social integration, the combined work of patients, families and staff has yielded results. Based on the most recent data, after three years of treatment, the number of users who are active (working, studying or volunteering) rose from 24% to 71%, and the majority (56%) became financially self-sufficient (compared to 28% before entering treatment) .
“What I like about the 388 is that it is a house that is more open to external life, which does not marginalize us, which does not isolate us, which does not cut our ties with the outside world. Here, I feel like I am rebuilding my life in a solid way, with better perception, a better guide to face external life.”
One of the main goals of the team is to avoid hospitalisation. Accordingly, in addition to regular outpatient psychiatric care, the centre is open 24/7 so its staff can answer phone calls and provide more intensive social support when needed. If this isn’t enough, 4 bedrooms (with 5 beds) are available for short-term stays during acute crises. The idea behind this is to allow users a safe and open environment to work and reflect on their crises as they emerge, so that they can ultimately understand the meanings of the crises, and manage their crises with new tools. Those measures, combined with the clinic’s integrative care, allow for a significant reduction in hospital stays: throughout their first three years of treatment, users spent 78% less days in a hospital than compared to the three years before they began attending the centre .
“During my last hospitalisation, I told that I was hearing voices: “Oh, just don’t pay attention to them !” If I can’t talk about them, if I can’t approach them, learn to deal with them, try to understand them, try to understand what they are doing here, their reason, their cause, if we don’t treat them, imagine the consequences of a psychosis, after which we end up in the hospital twice a year!”
A psychoanalytic approach to psychiatric symptoms can sometimes diverge from the neurobiological perspective, particularly when it comes to the meaning of these symptoms. Psychodynamic therapists generally tend to explore the inner world in which symptoms arise, guiding the patient to gain knowledge about the meaning of symptoms. At the “388”, psychiatrists share this attitude towards psychotic symptoms and extend it to their understanding of the role of antipsychotic drugs. Even if there is absolutely no forced treatment in the centre, psychiatrists still follow up-to-date pharmacotherapeutic guidelines. However, they may focus on patients’ attitudes towards medication, exploring their perceptions and trying to reach an agreement before prescribing. The purpose behind pharmacologic treatment isn’t necessarily to eliminate symptoms per se, but to reduce them enough to allow for self-direction, creative activities, psychotherapy and social integration.
“A comparison: drugs are a little bit like a band-aid, and when you pull the band-aid off, it bleeds again. With psychoanalysis, you don’t need a band-aid anymore, the wound has healed!”
Predictably, because of what may seem like political, ideological or economical reasons, since its foundation the “388” has been somewhat marginalised by traditional psychiatric institutions. In the beginning of the 2000’s, the “388” had to fight for its very existence: critics argued that it should close, as psychoanalysis is irrelevant. In response to these concerns, in 2002, an independent committee was appointed by Quebec’s Health Ministry to settle the debate. Through its study, the committee concluded that considering the excellent quality of medical care, the global approach and the high rates of satisfaction among users and families, the “388” should preserve the program as it was being administered. It is indeed what the “388” did, and what it intends to keep doing. Yet, because of substantiahttps://joannamoncrieff.com/2018/01/15/guest-blog-the-388-a-psychoanalytic-centre-for-the-treatment-of-psychosis/l reforms being carried out in the mental health field in the province, the centre’s current form may again be jeopardized in the upcoming years. We may however remain optimistic, for though the center has gone through many trials and tribulations, it has survived, supported by the trust of patients and their families. In these terms, we may conclude this brief presentation of the “388” by reflecting on the words of one user:
“I think that at the 388 they believe in the power of humans, in the humanism that inhabits in all of us and that everything is possible with this humanism, with this humanist approach which gives us back our dignity and our self-esteem. Step by step, we reconstruct then we recreate our lives.”

recommended reading, by no means exhaustive:
-A Clinical Introduction to Lacanian Psychoanalysis, The Lacanian Subject
Bruce Fink is a practicing analyst and writes very clearly about Lacan from that persepctive
-After Lacan: Clinical Practice and the Subject of the Unconscious
Collection put together by GIFRIC members, the group that runs the 388
-Contemporary perspectives on Lacanian theories of psychosis
-Second Thoughts
Collection of essays by Wilfred Bion, his theories of psychotic thinking are fascinating and off the wall too
-Anything put out by ISPS
-Ordinary Psychosis and The Body: A Contemporary Lacanian Approach 2014th Edition
Cool investigations of 'mild' psychoses
-Operators and Things: The Inner Life of a Schizophrenic
Absolutely captivating first-person narrative of psychosis, definitely recommend
-The Subject of Psychosis: A Lacanian Persepctive
Covers one of the two major contemporary Lacanian theories on psychosis
-On Being Normal and Other Disorders
Cool book on Lacanian psychodiagnostics
-Schizoid Phenomena, Object Relations and the Self
Harry Guntrip is one of my favorite object relations authors. Talks about schizophrenia and related disorders from an object relations perspective
-The Divided Self
Classic existential psychoanalytic text

fellow psychotics, lets get readin

c_man posted:

why do so many communists like lacan so much?

aside from clinical applications, i also like people like lasch and TLP and arrghshell's blog posts (https://n0p3.net/) where she talks about narcissism

drwhat posted:

i've been wondering for a few years what the social/community integrative stuff would do for someone dealing with genuinely severe dissociative traits, like huge memory gaps, personality changes, inability to integrate knowledge of past actions, etc. i think it's nice and helpful but not enough, though traditional psychoanalysis doesn't seem to have any good answer for it either other than "maybe do yoga or dance because somatic stuff helps and talk a lot". you guys have any thoughts?

dissociation and dissociative disorders have their origin in the trauma-based modality and not so much PA, afaik. this book https://www.amazon.com/Psychosis-Trauma-Dissociation-Perspectives-Psychopathology/dp/0470511737 (it's on libgen) is a really informative read

c_man posted:

why do so many communists like lacan so much?

lacan's core concepts involve disavowed desire and how it can radically alter interpersonal/social behaviour, which is necessarily of interest to anyone left of tradicionalismo

jansenist_drugstore posted:

psychiatry has no boundaries because it works from a normative ethic that is very flexible to fit in with whatever power structures are at play.

i think this is very important and makes it hard to come up with the line "psych(iatry/ology) has to be scrapped wholesale." admittedly it's hard for me to think clearly on this point because ᴍʏ ᴡɪꜰᴇ is a practicing clinical psychologist so i'm legally obligated to say that what she does is "useful."

but anyway my "embryonic problems" include the jabs cohen made at soviet/chinese psychiatry. so he writes off the soviet "sluggish schizophrenia" as a "labeling of political dissidents as mentally ill that intensified after Stalin's death." again it's my knowledge here that is embryonic. but what dialectical materialism obviously implies is that "mental illness" cannot be abstracted from the specific historical moments. there is a strikingly obvious class difference between "western schizophrenia" and "sluggish schizophrenia": the latter was employed to literally label anti-soviets/reformists as "mentally ill," and at least on paper that sounds pretty cool (even if terminologically unacceptable to the modern "mental health advocate"). from the book:

In fact, the belief in this label by Soviet psychiatry was so strong that when [Mikhail Gorbachev] began to speak the language of reform in the mid-1980s, some worried that he was showing all the signs of having this mental illness

i have a suspicion that lots of answers can be (have been?) gleaned from a study in this direction but unfortunately cohen refuses to engage. instead he comes off sounding like a liberal wikipedia contributor on this point.

nearlyoctober posted:

jansenist_drugstore posted:


psychiatry has no boundaries because it works from a normative ethic that is very flexible to fit in with whatever power structures are at play.



i think this is very important and makes it hard to come up with the line "psych(iatry/ology) has to be scrapped wholesale." admittedly it's hard for me to think clearly on this point because ᴍʏ ᴡɪꜰᴇ is a practicing clinical psychologist so i'm legally obligated to say that what she does is "useful."

but anyway my "embryonic problems" include the jabs cohen made at soviet/chinese psychiatry. so he writes off the soviet "sluggish schizophrenia" as a "labeling of political dissidents as mentally ill that intensified after Stalin's death." again it's my knowledge here that is embryonic. but what dialectical materialism obviously implies is that "mental illness" cannot be abstracted from the specific historical moments. there is a strikingly obvious class difference between "western schizophrenia" and "sluggish schizophrenia": the latter was employed to literally label anti-soviets/reformists as "mentally ill," and at least on paper that sounds pretty cool (even if terminologically unacceptable to the modern "mental health advocate"). from the book:



In fact, the belief in this label by Soviet psychiatry was so strong that when began to speak the language of reform in the mid-1980s, some worried that he was showing all the signs of having this mental illness



i have a suspicion that lots of answers can be (have been?) gleaned from a study in this direction but unfortunately cohen refuses to engage. instead he comes off sounding like a liberal wikipedia contributor on this point.

its interesting that the discourse around soviet psychiatry is that is got more oppressive after stalin's death. that's sort of counter to the way most things are talked about, and you sometimes hear 'stalin had this guy committed to an asylum' or what have you as an anticommunist thing. so what changed? what were they actually doing under stalin? gorbachev being called mentally ill for being a revisionist is really funny, also

Petrol posted:

karphead posted:

self-realizing how fragile the mind is a harsh lesson in life but it will make you stronger if you get thru it

not magically though. getting stronger still takes work.

you're nuts