À travers la restitution d’un récit clinique, nous tentons de saisir comment la prise compulsive de toxiques s’articule avec la défaillance de l’environnement familial. Nous essayons par ailleurs de démontrer la pertinence de la prise en charge des addictions chez les sujets psychotiques dans l’espace multiréférentiel de la psychothérapie institutionnelle.

L’analyse du cas de Léonard s’appuie sur les théories métapsychologiques et les principes pluridisciplinaires de la psychothérapie institutionnelle. Sont privilégiées les notions du Collectif et du transfert dissocié chez le sujet psychotique conceptualisées par J. Oury ; les concepts winnicottiens du miroir et de l’objet transitionnel ; les procédés autocalmants théorisés par l’École psychosomatique de Paris ; divers postulats plaidant contre la pureté des structures psychopathologiques (W.R. Bion, C. Chaperot, M. Czermak, R. Chemama, J.-D. Nasio).

L’observation de Léonard, qui évolue dans l’espace transversal et multitransférentiel de la psychothérapie institutionnelle depuis dix mois, tout en possédant à son actif de nombreuses années de psychothérapie dans un cadre duel, permet de déceler une immense carence affective et une animosité vis-à-vis de ses parents, toutes deux dissimulées derrière un récit policé idéalisant l’amour parental. S’il se montre toujours peu apte à élaborer ses sentiments envers ses géniteurs, le patient, sujet à des alcoolisations massives et à tous types d’auto-intoxications, commence, de par son intégration dans le Collectif, à afficher une meilleure maîtrise de ses comportements compulsifs.

L’observation clinique à l’appui de l’anamnèse conduit à l’hypothèse d’un désinvestissement précoce du patient par sa mère, aggravé par la présence matérielle d’un père psychiquement absent. La prise de toxiques se dessine comme une automédication colmatant les failles narcissiques consécutives à cette double carence et comme un effort de faire sans l’autre. Par ailleurs, la coexistence de traits névrotiques et psychotiques chez Léonard nous incite à questionner le purisme de la psychopathologie structurale commune.

L’hypothèse diagnostique qui ressort de nos analyses est celle d’une psychose partielle dysthymique. Nous défendons la thèse selon laquelle cette structuration psychique de Léonard plonge ses racines dans le pacte inconscient de ses parents pour lui interdire de naître et d’exister psychiquement. Par ailleurs, les investissements transférentiels du sujet psychotique, capables de se diffracter et de se diriger indistinctement vers toute personne qui gravite autour de lui, ainsi que vers une foultitude d’objets, nous permettent de concevoir l’espace pluriel de la psychothérapie institutionnelle comme un lieu d’objets vivants susceptibles de prendre la place des objets toxiques non humains.

The aim of this article is to present a clinical case in order to demonstrate how the compulsive use of toxic substances articulates with the shortcomings of the family environment. It also aims to show the pertinence of the treatment of addictions in psychotic patients within the multireferential setting of institutional psychotherapy.

The analysis of the case of Léonard is based on metapsychological theories and the pluridisciplinary principles of institutional psychotherapy. More specifically, the article centers on the following: the Collective, and dissociated transfer, conceptualized by J. Oury; the Freudian theory of identification, melancholy and mania; Winnicott's concepts of the mirror and the transitional objet; the Complex of the Dead Mother by A. Green; the self-calming techniques theorized by the Psychosomatic School of Paris; the function of toxic substances as being pharmakon, namely poison and remedy, propounded by S. Le Poulichet; and theories disputing the purity of psychopathological structures (W.R. Bion, C. Chaperot, M. Czermak, R. Chemama, J.-D. Nasio).

The institution where I met Leonard encourages the free circulation of patients, their active participation in their cure, and cross-disciplinary treatments with special emphasis on sociotherapy, and constant work on the atmosphere, analysis and exploitation of multifocal transfers specific to psychotic patients. This approach appears to be liable to reduce both psychological alienation and social estrangement. The observation of Leonard, who has been testing this setting for 10 months after having experienced numerous years of individual psychotherapy, evidences tremendous emotional deprivation and animosity towards his parents, hidden behind the polished narrative of an idealized parental love. The patient, who is prone to massive absorption of alcohol and to several other types of self-intoxication, although he still does not seem capable of elaborating his emotions towards his progenitors, is beginning to gain some control over his compulsive behaviours as a result of his integration into the Collective setting.

Clinical observation, backing up the anamnestic approach, leads to the hypothesis of an early withdrawal of the emotional involvement of Leonard's mother, who suffered from depression at the time of her son's birth, following the loss of her own father. This primitive disaffection most probably had disastrous consequences on her son's psyche, since a depressed mother is likely to be a psychologically “dead mother” (A. Green), a distorting reflection of her baby's internal image and a terrifying mirror of his destiny (W. Winnicott). The patient explains the calm that drugs provide him with, but refuses to admit that he derives any satisfaction from them, which suggests that the use of toxic substances is a self-calming strategy resembling the compulsive and repetitive movements or tics deployed by an infant whose mother is physically or psychologically unavailable and/or unwilling to satisfy his needs. The emotional abandonment of Leonard was probably compounded by a substantially absent father, preoccupied with success, money and his spouse's unfaithfulness. Suicide attempts with his father's painkillers or vehicle, along with the explicit perception of his father as toxic, could provide some understanding of Leonard's compulsive behaviour as being a means of expending his anger towards his father. Overall, the act of taking toxic substances appears as a form of self-medication liable to fill the narcissistic gaps caused by this dual deprivation in his early family environment, an effort to “do without” the other. Moreover, the coexistence of neurotic and psychotic mechanisms in Leonard's mental function encourages debate on the existence of pure, unadulterated psychopathological structures.

This suggests a diagnostic hypothesis of partial dysthymic psychosis, that is to say a mainly psychotic structure with elements of mania and melancholy, dominated by foreclosure and compounded by neurotic features caused by the mechanism of repression. I suggest that the structuring of the patient was heavily influenced by his parents’ unconscious pact to forbid their son to be and to be born. Furthermore, the fragmented transference investments that psychotic patients tend to make without distinction towards any person who gravitates around them, as well as towards a wide range of objects, leads us to conceive the pluralistic setting of institutional psychotherapy as a setting of living objects able to pacify the internalized, noxious parents and replace the toxic, inhuman, fetishized objects.