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This article examines the use of clay modeling as an instrument for clinical analysis of the relation to one's own body and to the object. While modeling is a widely-used medium in therapeutic work, we present here the use of the modeled self-portrait as a projective method in a research situation involving sensorial mediation using touch. The aim is to understand how the subject invests and engages a relation with this object, based on the way s/he invests and represents her/his body and sensations. The modeling situation was proposed individually to 19 participants at the first of six meetings. The choice of the modeled self-portrait in this research project is inspired by a psychoanalytical epistemology that enables us to understand the unconscious psychic dimensions of body image and the relation to the object, as well as the concepts of mediation, the projective situation, and transference. In the absence of a pre-existing reference to a systematized methodology for analyzing the self-portrait with modeling clay, we referred to psychoanalytic work on projective tests to construct a qualitative analysis grid based on the material collected. The modeled self-portrait enabled us to take into consideration, from an economic, dynamic, and topical point of view, on the one hand, the content that emerged in the modeling and in the verbalizations that accompanied it, and, on the other hand, the characteristics of the modeling process itself. The modeling situation gave rise to regressive and projective movements, leading the participants to express key elements of their personal history, their sensory situation, and the areas of the body invested or disinvested, as well as their psychic behaviors in relation to the object in the present of this research encounter. We identified four ways in which participants related to modeling, depending on their subjectivity and their position in the research process. The form given to the modeling, its structure, and the parts represented or not provided us with indications of certain features of the participants' body image and the way in which they were able to express it in the space-time of this encounter. We hypothesize that through its connections with the subject's body image, the three-dimensional self-portrait expresses the way in which participants invest their bodies, and sometimes body zones linked to the senses, such as touch, through the modeling activity itself, but also other senses through the elements represented or not, verbalized or not, about the created-modeled object. We present some considerations on the complex connections between the relationship to modeling, to the object of sensory mediation through touch, and to autobiographical speech in the interview situation, considering the participants' verbal and non-verbal productions during the process of this research. Finally, we present the limits of the collection and analysis of results in the context of this research and the present article. The use of the modeled self-portrait has brought out elements that enable us to better understand the psychological underpinnings of the different relations to the mediating object that the participants expressed in this research. Insofar as self-portrait calls upon unconscious elements of both body image and relation to the object, it encounters resistance and defensive modalities in the subject's own psychic functioning. [ABSTRACT FROM AUTHOR]

S'appuyant sur les fondements théoriques de la psychanalyse, cet article pose la problématique clinique qui a été à l'origine de la conception et la mise en place d'un dispositif de médiation thérapeutique par le son, la musique et la vibration proposé à des patients adolescents souffrant d'anorexie mentale. Après une description du dispositif, les résultats d'une expérience pilote réalisée au département de psychiatrie de l'adolescent et du jeune adulte de l'Institut Mutualiste Montsouris sont présentés. Ils ouvrent des perspectives nouvelles pour comprendre la singularité et la pertinence de ce dispositif face aux difficultés rencontrées dans le travail clinique avec ces jeunes patients. La désaffectation du corps et le refus des liens dans le rapport à l'objet en deçà de la relation à l'autre se présentent comme des modalités de défense psychique face aux menaces du vécu de débordement pulsionnel réactivé par les métamorphoses de la puberté. Le cadre de la thérapie fondée sur la parole et l'associativité, étayée sur la relation transférentielle, vient souvent renforcer ces angoisses et, par conséquent, les défenses chez ces patients organisés autour des symptômes anorexiques. Dans le but de favoriser le désamorçage progressif des défenses et la mise en marche des mouvements psychiques par l'associativité, un dispositif clinique innovant de médiation thérapeutique par le contact corporel avec les vibrations liées au son et à la musique a été conçu et proposé. Huit adolescents, dont un garçon et sept filles, âgés de 14 à 19 ans, hospitalisés pour anorexie mentale ont participé à cette expérience clinique. Ainsi, pendant cinq séances d'atelier, les patients ont exploré leurs sensations corporelles en présence de deux psychologues cliniciennes. Les sensations corporelles étaient suscitées par le jeu avec des séquences sonores et musicales perçues à travers le contact avec quatre objets médiateurs sonovibrotactiles : une table, un ballon, un plaid et un coussin repose-nuque. Le discours, les gestes et les actions des patients pendant les séances d'atelier ont été révélateurs des manières dont ils ont investi psychiquement les objets sensoriels du dispositif. Les séquences sonores des pulsations cardiaques et des événements aquatiques associés à la mer (dont plusieurs représentations ont été explorées), avec leurs vibrations, ont été particulièrement investies. Les objets médiateurs ont été explorés avec une diversité de postures corporelles. Les sensations suscitées par les rapports psychocorporels à ces objets ont fait émerger des représentations et des affects liés au vécu que les patients ont exprimé dans la prise de parole avec les psychologues. L'expression verbale et non verbale des patients nous a permis de repérer trois grandes catégories d'analyse : l'expression de différents types de difficultés à jouer avec le dispositif ; l'expression des sensations corporelles suscitées et le rapport des patients au plaisir ou au déplaisir associé à ces sensations ; l'expression de contenus liés au vécu de la maladie, à la famille, l'inconnu, la solitude, la peur et l'angoisse, la mort, et l'affect entre autres. Les objets d'expérience ont rempli en ce sens une fonction projective, d'embrayeurs d'une dimension associative et d'un travail clinique possible. Ce dispositif clinique de médiation, par ses objets sonovibrotactiles, est attractif pour les adolescents. Il introduit cependant chez le sujet une expérience sensorielle surprenante et peu familière, potentiellement troublante, faisant surgir l'inquiétante étrangeté de l'intime pulsionnel qui échappe au sujet. Le sujet récupère par cet intermédiaire des sensations corporelles intenses qui réactivent des expériences primaires enfouies. En ce sens, l'intérêt mais également le risque de ce dispositif, c'est qu'il touche aux zones profondes du corps, pouvant ainsi déjouer les barrières des mécanismes défensifs et faisant ressortir des contenus psychiques ayant une grande charge affective. C'est pour cela que ce dispositif ne peut pas être mis en place sans le clinicien, qui soutient par sa présence la capacité de porter une attention aux effets psychiques provoqués par ces sensations corporelles et de les reconnaître. Cet étayage permet également de ne pas laisser le sujet livré à lui-même. La singularité de ce dispositif consiste en ce qu'il propose au sujet une constellation d'objets malléables de différents types comme vecteurs de son rapport à ses propres objets pulsionnels. Ce dispositif est en ce sens pensé comme une médiation à visée thérapeutique pouvant favoriser, selon les possibilités psychiques des patients, le réinvestissement libidinal des zones corporelles désaffectées dans les anorexies mentales. Les éprouvés corporels suscités et réactivés par le contact avec les différents types d'objet actualisent des traces mnésiques qu'il est fondamental de reconnaître dans le cadre du lien transférentiel entre le clinicien et le patient, notamment dans l'échange discursif. Based on the theoretical foundations of psychoanalysis, this article outlines the clinical problem at the origin of the conception and the implementation of a therapeutic mediation platform using sound, music, and vibration for adolescent patients with anorexia nervosa. After a description of the platform, the results of a pilot experience carried out in the adolescent and young adult psychiatry department of the Institut Mutualiste Montsouris are presented. They open up new perspectives for understanding the singularity and the relevance of this platform with respect to the difficulties encountered in clinical work with these young patients. The disaffectation of the body and the refusal of links in the relation to the object behind the relation to the other present themselves as modalities of psychic defense responding to threats coming from the experience of instinctual overflow, reactivated by the metamorphoses of puberty. The framework of therapy based on speech and associativity, supported by the transference, often reinforces the anxieties and, consequently, the defenses of patients organized around anorexic symptoms. In order to promote the progressive defusing of defenses and the activation of psychic movements through associativity, an innovative clinical platform for therapeutic mediation through bodily contact with vibrations linked to sound and music has been designed and proposed. Eight adolescents, a boy and seven girls, aged 14 to 19, hospitalized for anorexia nervosa participated in this clinical experience. During five workshop sessions, the patients explored their bodily sensations in the presence of two clinical psychologists. The bodily sensations were provoked by the play of sound and musical sequences perceived through contact with four audiovibrotactile objects : a table, a balloon, a blanket, and a neck pillow. The speech, gestures, and actions of the patients during the workshop sessions revealed the ways in which they psychically invested the sensory objects of the platform. The sound sequences of heartbeats and aquatic events associated with the sea (several representations of which have been explored), with their vibrations, were the site of special investments. The objects were explored through a variety of body postures. The sensations called up by the psycho-corporeal relationships with these objects brought to light representations and affects linked to life experiences that patients had expressed in speaking with psychologists. The patients' verbal and non-verbal expression allowed us to identify three main categories of analysis: the expression of different types of difficulty in engaging with the platform; the expression of the bodily sensations aroused and the relationship of patients to the pleasure or displeasure associated with these sensations; the expression of contents related to their experience of disease, to the family, to the unknown, to loneliness, fear and anxiety, death, and affect, among others. In this sense, the experimental objects fulfilled a projective function, as shifters of an associative dimension and possible clinical work. This clinical mediation platform, through its audiovibrotactile objects, is attractive to adolescents. However, it introduces into the subject a surprising and unfamiliar, potentially disturbing sensory experience, bringing out the uncanniness of the intimate drive that subject cannot control. The subject experiences intense bodily sensations that can reactivate buried primary experiences. In this sense, the interest but also the risk of this platform is that it touches the deepest areas of the body, thus allowing it to overcome the barriers of the defensive mechanisms and to bring up psychic contents with a strong emotional charge. This is why this platform cannot be put in place without the clinician, who by his/her presence supports the ability to pay attention to the psychic effects provoked by these bodily sensations and to recognize them. The clinician's anaclitic function also means that patients are not left to their own devices. The singularity of this platform consists in that it offers the subject a constellation of malleable objects of different types as vectors of her/his relationship to own instinctual objects. In this sense, this platform is thought of as mediation with a therapeutic aim which can encourage, depending on the psychic possibilities of the patients, the libidinal reinvestment of disaffected body areas in anorexia nervosa. The bodily experiences aroused and reactivated by contact with the different types of object update memory traces that it is essential to recognize in the context of the transferential link between the clinician and the patient, especially in discursive exchange. [ABSTRACT FROM AUTHOR]

Dans cet article, nous montrerons que la croyance en une « métamorphose » identitaire du sujet en obésité grâce à la chirurgie bariatrique est une construction imaginaire que soignants et soignés ont en partage dans ce type de clinique. Nous analyserons les causes et les répercussions que ces fantasmes peuvent avoir sur la prise en charge, tant au niveau des vécus des patients que des pratiques des soignants. Enfin, nous proposerons l'idée que l'événement chirurgical et ses conséquences vont s'inscrire, à l'inverse d'une « métamorphose », dans une continuité subjective pour la personne opérée ; en témoigne l'insistance de certaines expressions symptomatiques à travers et au-delà des changements organiques ou comportementaux liés à l'opération. Il s'agira ainsi de réfléchir aux modalités d'accueil et d'accompagnement des personnes en obésité lors d'une prise en charge en chirurgie bariatrique aujourd'hui. In this study, we will show that the believing of an "identity metamorphosing" of the subject with obesity by bariatric surgery is a fantasy construction built by both patients and caregivers. We will analyze the reasons and the repercussions of these fantasies on the care, both on the patients' subjective experiences and on caregivers' practices. At last, we will propose the idea that the surgical event and his consequences will be inscribed, at the opposite of a "metamorphosis", in a subjective continuity for the operated person, as the insistence of symptomatic expressions across and beyond the organic and compartmental changes linked to the surgery reflects it. Most of the patients investigated for this study were treated with Sleeve Gastrectomy and Roux-en-Y Gastric Bypass but some of them were not treated yet and expected for a surgery. In all cases (i.e. when they were not operated yet and when they were asking for a second surgery because in failure by gaining weight), they were brought to discuss on their surgery request. Surgery-experienced patients also have to comment the surgery's effects on their body and its image, their eating behaviors and their relationships with the others (companion, friends, family, etc.). For caregivers, the results are extracted from different clinical discussions about patients or about ways of caring all along the multidisciplinary support. Patients and caregivers were both asked to talk about their representations on bariatric surgery. We observed two types of fantasies: "split" fantasy built by patients and "recovery" fantasy built by caregivers. The "split" fantasy is the believing of a magical and ideal surgery that allows "identity metamorphosing" of the subject with obesity. For these patients, "split" fantasies can be related to the desire of the other or can appear through weight's objectives. For the caregivers, and as "split" fantasies, "recovery" fantasies can be related to an idealization of the operation in itself and the obesity "psychiatrization". On the other side, we have seen that some psycho-sensory symptoms emerged after surgery: patients present disgust for aliments they used to appreciate. By discussing with these patients, we realize that these aliments were associated with traumatic experiences and memories that potentially lead them to construct their obesity. These symptoms seem to be an opened-door to the operated subject's unconscious and are related to the subject's psychical continuity. The identity metamorphosing resulting from bariatric surgery is a fantasy built by both patients and caregivers. These fantasies have an influence on the medical support and potentially lead the treatment to failure. They should be identified and analyzed before the request, during the transformations due to the operation itself, and after weight stabilization (when the operated subject continues to reorganize his relationships to the other and to the culture pressure). Also, as the symptoms produced by bariatric surgery mobilize traumatic memories from before, they reveal a subjective truth: the traumatic past cannot be erased by body changes. And if the patient's past continues to be ignored by caregivers, it is condemned to repeat itself and potentially compromising the treatment at term. Thus, caregivers should be able to pay attention to the subjective continuity of the patient's history in order to ameliorate the reception and the accompaniment of persons with obesity in a bariatric surgery procedure. [ABSTRACT FROM AUTHOR]

Résumé Objectifs Il s’agit dans cet article d’interroger les nouvelles pratiques de chirurgie bariatrique dans la clinique de l’obésité puisque les effets qu’elles produisent peuvent s’avérer mystérieux sur le plan organique, parfois problématiques, jusqu’à mettre en échec la démarche thérapeutique initiale. Chez une majorité de patients opérés, l’apparition de modifications olfactives et gustatives à la suite de l’intervention met en lumière le fait que la transformation du corps réel par la chirurgie provoque des effets de remaniements non seulement organiques mais aussi psychiques. Ce bouleversement de l’organisation pulsionnelle et des investissements libidinaux, soutenu par les modifications corporelles, prendrait sa source dans l’actualisation du mécanisme du refoulement « organique » chez le patient opéré. Convoqué par la clinique, ce concept freudien oublié permettrait de tirer des pistes de réflexion pour la compréhension théorique et l’amélioration de la prise en charge psychique des sujets en situation d’obésité et opérés d’une chirurgie bariatrique. Méthode Les patients rencontrés ont été opérés d’une chirurgie bariatrique de type Sleeve gastrectomie ou de type Bypass gastrique . Il a été proposé aux patients de parler de leur expérience de la chirurgie bariatrique et du retentissement des modifications corporelles sur leur comportement alimentaire, sur leur rapport au corps et sur leur rapport à l’autre. Résultats Les modifications psychosensorielles post-chirurgicales attesteraient de l’actualisation du processus de refoulement « organique » et du remaniement de l’organisation pulsionnelle qui lui est connexe. La coupure du corps réel provoquée par ce type d’intervention va avoir des incidences sur le refoulement « organique » qui va s’actualiser et se renforcer chez le sujet opéré. Les représentations qui, avant l’intervention, amenaient le sujet vers un plaisir organique et psychique auto-érotique vont être ainsi réprimées du champ de la conscience car les conditions d’accès à ce plaisir érogène ont été modifiées. Les objets, notamment alimentaires, qui se liaient par association à ces représentations refoulées, seront perçus consciemment par le sujet comme vecteurs de déplaisir. Ces objets, auparavant source d’un certain plaisir érogène pour le sujet, vont ainsi devenir objets de dégoût et de répulsion après la survenue des changements corporels. Discussion Les changements olfactifs et gustatifs dans la perception des aliments représenteraient non seulement l’impact de la chirurgie sur la vie psychique du sujet opéré, mais signaleraient paradoxalement que derrière les aliments qui « refoulent » et qui sont maintenant mis à distance par le sujet se cacherait en réalité ce qui a été refoulé psychiquement lors de l’actualisation du refoulement « organique ». Ces modifications psychosensorielles sélectives et les relations alimentaires particulières qui sont visées par ces changements semblent être régulièrement mises en lien par les patients eux-mêmes avec certains aspects de leur histoire personnelle et intime, avec des souvenirs ou des représentations d’évènements dans lesquels la sexualité infantile s’est retrouvée dans l’écueil, parfois traumatique, du rapport à l’autre. La verbalisation de ces souvenirs-écrans, convoqués depuis ces changements perceptifs sélectifs issus de l’actualisation du refoulement « organique », ouvrirait ainsi une nouvelle voie d’accès vers l’élaboration d’une vérité subjective inconsciente pouvant, par ailleurs, être en lien avec l’édification de la construction symptomatique de l’obésité. Conclusion Cette étude souligne l’importance du refoulement « organique » pour penser ces modifications psychosensorielles sélectives après la chirurgie bariatrique et pour comprendre le réaménagement psychique conduisant à ces changements du comportement alimentaire. Il conviendrait de prendre en considération l’impact des éléments spécifiques présents dans la construction symptomatique de l’obésité (oralité, image du corps, structuration familiale), en fonction de leurs différentes modalités d’expression pour chaque sujet, sur le refoulement « organique » après la modification chirurgicale du corps. Mais il s’agirait également de cerner, dans la construction symptomatique propre à chaque sujet, les formes prises originairement par le refoulement « organique » avant même son actualisation par les effets de la chirurgie bariatrique. Ces deux étapes (pré et post-opératoire) sont essentielles pour la compréhension des éléments psychiques conduisant à un échec thérapeutique dans le traitement chirurgical de l’obésité, afin d’améliorer les soins et de limiter une rechute de la maladie. Objectives This study aimed to investigate the new practices of bariatric surgery in the clinical treatment of obesity, since the effects produced by these procedures are organically enigmatic, sometimes problematic, and may cause treatment failure. Thus, in many operated patients, the psycho-sensory changes following surgery, such as olfactory and taste mutations (from “pleasure” to “displeasure”), show that these technical transformations of the body cause organic, and also psychic reorganizations. These disturbances in instinctual organization and in libidinal investments, underpinned by profound bodily changes, seem to originate from the updating of the mechanism of “organic” repression in the patient. Derived from clinical practice, this forgotten Freudian concept raises points of interest for the theoretical understanding and improvement of the psychic management of patients with obesity undergoing bariatric surgery. Method The patients investigated were treated with bariatric surgery, including Sleeve gastrectomy or Roux-en-Y Bypass . They were asked to comment on their experience of bariatric surgery and on the impact of the body changes on their eating behaviours, their relationship with the body and with the others. Results In most of the patients, bariatric surgery brought about olfactory and taste changes. These psycho-sensory changes seem to attest to an updating of the process of “organic” repression and to a restructuring of the associated instinctual organization. In these patients, cutting into the reality of the body appears to have an impact on “organic” repression, which is reshaped, updated and reinforced for most of the operated subjects. Consequently, the representations that, before surgery, brought the subject organic, psychic, self-erotic pleasure appear to be repressed from the field of consciousness because the conditions underpinning access to this erotic pleasure have been altered. Therefore objects, in particular food items, which are bound by association to these repressed representations, could be consciously perceived by the operated subject as vectors of displeasure. These objects, previously providing erogenous pleasure, will thus become sources of disgust and repulsion following the bodily changes. Discussion The olfactory and gustatory modifications in the perceptions of food observed after bariatric surgery underline the impact of this procedure on the psychic life of these patients. Behind the “disgusting” foods now pushed away could lie what was repressed when the “organic” repression was updated. These selective psycho-sensory changes and the dietary relationships affected by these changes seem to be regularly linked by the patients themselves to certain aspects of their personal and intimate history, including memories or representations of events in which infantile sexuality was confronted with the pitfalls of relationships with the others. The verbalization of these screen-memories, appearing after these selective perceptive changes and resulting from the updating of “organic” repression, could thus open a new way of access to the elaboration of an unconscious subjective truth, which may be linked to the elaboration of the symptomatic construction of obesity. Conclusion This study underlines the importance of the notion of “organic” repression to approach these psycho-sensory changes after bariatric surgery and to understand the psychic reorganization leading to these changes in eating behaviour. It is important to consider the impact on the process of “organic” repression of the specific elements present in the symptomatic construction of obesity (orality, body image, family structure), according to their different modes of expression for each subject, following surgical modification of the body. In addition, it is important to understand the forms originally taken on by “organic” repression, before its reshaping or updating by the effects of bariatric surgery, in the light of the specificity of the symptomatic construction of each subject. These two pre- and post-operative steps are essential in the understanding of the psychic elements leading to therapeutic failure in the surgical treatment of obesity, in order to improve quality of care and to limit relapses. [ABSTRACT FROM AUTHOR]

Objectives This study aimed to investigate the new practices of bariatric surgery in the clinical treatment of obesity, since the effects produced by these procedures are organically enigmatic, sometimes problematic, and may cause treatment failure. Thus, in many operated patients, the psychosensory changes following surgery, such as olfactory and taste mutations (from “pleasure” to “displeasure”), show that these technical transformations of the body cause organic, and also psychic reorganizations. These disturbances in instinctual organization and in libidinal investments, underpinned by profound bodily changes, seem to originate from the re-contextualisation of the mechanism of “organic” repression in the patient. Derived from clinical practice, this forgotten Freudian concept raises points of interest for the theoretical understanding and improvement of the psychic management of patients with obesity undergoing bariatric surgery. Method The patients investigated were treated with bariatric surgery, including Sleeve gastrectomy or Roux-en-Y Bypass . They were asked to comment on their experience of bariatric surgery and on the impact of the body changes on their eating behaviours, their relationship with the body and with others. Results In most of the patients, bariatric surgery brought about olfactory and taste changes. These psychosensory changes seem to attest to a re-contextualisation of the process of “organic” repression and to a restructuring of the associated instinctual organization. In these patients, cutting into the reality of the body appears to have an impact on “organic” repression, which is reshaped, re-contextualised and reinforced for most of the operated subjects. Consequently, the representations that, before surgery, brought the subject organic, psychic, auto-erotic pleasure appear to be repressed from the field of consciousness because the conditions underpinning access to this erotic pleasure have been altered. Therefore objects, in particular food items, which are bound by association to these repressed representations, could be consciously perceived by the operated subject as vectors of displeasure. These objects, previously providing erogenous pleasure, will thus become sources of disgust and repulsion following the bodily changes. Discussion The olfactory and gustatory modifications in the perceptions of food observed after bariatric surgery underline the impact of this procedure on the psychic life of these patients. Behind the “disgusting” foods now pushed away could lie what was repressed when the “organic” repression was re-contextualised. These selective psychosensory changes and the dietary relationships affected by these changes seem to be regularly linked by the patients themselves to certain aspects of their personal and intimate history, including memories or representations of events in which infantile sexuality was confronted with the pitfalls of relationships with others. The verbalization of these screen-memories, appearing after these selective perceptive changes and resulting from the re-contextualisation of “organic” repression, could thus open a new path of access to the elaboration of unconscious subjective truths, which may be linked to the elaboration of the symptom construction of obesity. Conclusion This study underlines the importance of the notion of “organic” repression to approach these psycho-sensory changes after bariatric surgery and to understand the psychic reorganization leading to changes in eating behaviours. It is important to consider the impact on the process of “organic” repression of the specific elements present in the symptomatic construction of obesity (orality, body image, family structure), according to their different modes of expression for each subject, following surgical modification of the body. In addition, it is important to understand the forms originally taken on by “organic” repression, before its reshaping or re-contextualisation by the effects of bariatric surgery, in the light of the specificity of the symptom construction of each subject. These two pre- and post-operative steps are essential in the understanding of the psychic elements leading to therapeutic failure in the surgical treatment of obesity, in order to improve quality of care and to limit relapses. [ABSTRACT FROM AUTHOR]