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Le trouble de la personnalité borderline est un trouble psychiatrique fréquent qui apparaît à l'adolescence. La thérapie comportementale dialectique adaptée aux adolescents (TCD-A) a montré son efficacité dans la prise en charge psychothérapeutique des adolescents souffrant de conduites suicidaires ou d'auto-agressivité associées au trouble de la personnalité borderline. Au travers de notre étude nous avons souhaité explorer la faisabilité et l'acceptabilité, pour des adolescents présentant un TPL diagnostiqué ou des troubles de la régulation des émotions, d'un module TCD intitulé « tolérance à la détresse » proposé sur le mode d'un groupe multi-familles. Pour ce faire nous avons mis en place un groupe multi-familles de six adolescents et de leurs parents. L'acceptabilité et la faisabilité du protocole étaient excellentes. Les témoignages des adolescents et de leurs parents nous apportent des informations précieuses sur l'intérêt d'un tel groupe et sur les améliorations à introduire. La mise en place d'un tel groupe est une première en France et nous souhaitions montrer par notre étude pilote, sa faisabilité, son acceptabilité et ses effets afin de promouvoir son développement et son implémentation dans le contexte pédopsychiatrique français. Borderline personality disorder is a common psychiatric disorder emerging in adolescence. Dialectical Behavioral Therapy adapted to adolescents (DBT-A) has proven to be effective as a psychotherapeutic treatment for adolescents suffering from borderline-related behaviors, such as suicidal or self-aggressive behaviors. In our study, we were interested in exploring the feasibility and acceptability of a DBT-A module entitled "distress tolerance", which reduces borderline-related behaviors in borderline adolescents or undiagnosed adolescents who experience difficulties in regulating their emotions. To do this, we set up a pilot study with one multi-family treatment group of six adolescents and their parents. The treatment was fully accepted by all adolescents and parents with an excellent acceptability. Comments from adolescents and parents gave us valuable information about the great interest of a multi-family treatment group and potential improvements for its implementation. This is the first study exploring a DBT-A multi-family treatment group in France. It highlights its feasibility, acceptability and potential positive effects. Further studies are needed to promote the implementation and development of such interventions in the context of child and adolescent psychiatry in France. [ABSTRACT FROM AUTHOR]

Dans le monde, les technologies sont de plus en plus utilisées en psychothérapies, et plus largement dans le domaine de la santé mentale. Parmi ces technologies, les jeux vidéo et les robots ont donnée lieu à un grand nombre de recherches. Pour autant, ces études ne décrivent pas précisément : d'une part, les modalités d'utilisation de ces technologies dans les dispositifs en psychothérapie ; d'autre part, quel niveau de fonctionnement en psychothérapie (explicite ou implicite) est concerné par ces dispositifs. Cette recherche poursuit donc l'objectif de présenter les principales orientations thérapeutiques de ces dispositifs, tout en les croisant aux niveaux de fonctionnement en psychothérapie. Pour conduire cette revue, nous avons utilisé une perspective qualitative et conceptuelle, en suivant trois étapes clés (définition du périmètre de l'étude, recherche documentaire et analyse de la littérature), et consistant en une intégration des publications organisées d'une manière thématique, et regroupées ensuite par orientation en psychothérapie. D'une part, trois orientations thérapeutiques sont distinguées : l'utilisation des technologies comme des objets thérapeutiques en eux-mêmes (à la manière des serious game) ; l'utilisation de ces technologies pour faciliter l'adhésion, l'alliance et la communication thérapeutiques (« médiation relationnelle » soignant-patient ou psychothérapeute-patient) ; l'utilisation des jeux vidéo et des robots comme des cyber-médiations en psychothérapie (« médiation thérapeutique » psychothérapeute-patient). D'autre part, ces trois orientations ne semblent pas occuper le même espace au sein des deux niveaux de fonctionnement en psychothérapie. La différence entre la première et la troisième orientation semble tenir en la présence systématique ou non du psychothérapeute. Les limites de cette recherche sont nombreuses, la démarche étant essentiellement qualitative et conceptuelle. Des études complémentaires devront être entreprises. Par ailleurs, les limites potentielles de ces utilisations sont soulignées : les études contrôlées et randomisées sont rares, et les publications sans données expérimentales sont parmi les plus courantes. De plus, les données longitudinales font défaut, notamment en ce qui concerne le maintien et la généralisation des résultats dans le temps. Technologies are used increasingly today in psychotherapy and especially in the field of mental health. Among these technologies, video games and robots have given rise to a large amount of research. However, these studies don't describe precisely the modalities of use of these technologies in psychotherapeutic settings, or which, level of functioning in psychotherapy (explicit or implicit) is concerned by these devices. The aim of this research is to highlight the main therapeutic orientations of the devices while crossing them at the levels of functioning in psychotherapy. To conduct this review we used a qualitative and conceptual perspective and followed three key steps (definition of the perimeter of the study, documentary research and analysis of the literature). The literature has been organized in a thematic way and researches have been gathered according to their orientation in psychotherapy. Three therapeutic orientations are distinguished: the use of technologies as therapeutic objects in themselves (in the manner of serious games); the use of these technologies to facilitate adherence, alliance and therapeutic communication ("relational mediation" caregiver-patient or psychotherapist-patient); the use of video games and robots as cyber-mediations in psychotherapy ("therapeutic mediation" psychotherapist-patient). On the other hand, these three orientations do not seem to occupy the same space within the two levels of functioning in psychotherapy. The difference between the first and third orientations seems to be the systematic presence or not of the psychotherapist. The limitations of this research are numerous, the approach being essentially qualitative and conceptual. Further studies should be undertaken. Additionally, the potential limitations of these uses are highlighted: randomized controlled studies are rare and publications without experimental data are among the most common. Also longitudinal data are lacking, particularly with respect to the maintenance and generalization of results over time. [ABSTRACT FROM AUTHOR]

Cet article propose une revue de littérature concernant l'évaluation et l'efficacité des psychothérapies psychanalytiques et de la psychanalyse (PPP). Après avoir proposé une vue d'ensemble de l'évaluation des psychothérapies, nous reprenons les travaux portant sur l'évaluation empirique et quantitative des PPP avant de nous centrer sur leur évaluation qualitative et processuelle. Les résultats des études menées en ce domaine démontrent que les psychothérapies sont efficaces aussi bien sur le court terme que le long terme. Leur efficacité est le plus souvent indépendante de l'obédience théorique du clinicien. En revanche, les facteurs communs comme l'alliance thérapeutique ou les particularités du thérapeute sont des éléments prévalents de même que la durée et la fréquence des psychothérapies. Concernant plus précisément l'évaluation des PPP, celles-ci sont démontrées empiriquement comme étant efficaces pour la plupart des troubles psychiatriques. Plusieurs caractéristiques des PPP sont en outre corrélées de manière significative avec l'efficacité thérapeutique. L'évaluation qualitative et processuelle des PPP apparaît complémentaire à ce premier niveau d'évaluation empirique qui présente plusieurs limites (biais d'allégeance, indistinction des processus, pratiques de recherches questionnables, etc.) mises notamment en évidence par la crise de la reproductibilité. La méthodologie des Essais Contrôlés Randomisés propose une évaluation de surface à laquelle doivent être associées des approches fondées davantage sur la pratique clinique. L'approche du groupe de Boston, l'analyse des processus psychothérapiques par le Psychotherapy Q-Sort (PQS) ainsi que la modélisation du processus de symbolisation par l'École de Lyon sont trois paradigmes de recherche qualitatifs particulièrement riches de ce point de vue. Les PPP sont efficaces pour la plupart des troubles psychiatriques sur le court terme, en fin de thérapie et plusieurs années après celle-ci. Elles engendrent des transformations durables sur le plan des symptômes et de la personnalité. Elles apparaissent souvent plus efficaces que la pharmacothérapie et conduisent à des économies substantielles quand elles sont mises en œuvre dans des services de soin auprès de patients souffrant de pathologies variées. This article proposes a review of the literature concerning the evaluation and the efficacy of psychoanalytic psychotherapy and psychoanalysis (PPP). After proposing a global overview of the evaluation of psychotherapy, we sum up the empirical and quantitative evaluation of PPPs before focusing on their qualitative and process-based evaluation. Psychotherapies are very effective both in the short and in the long term. Their effectiveness is largely independent of the clinician's theoretical affiliation. Common factors such as the therapeutic alliance or the particularities of the therapist are prevalent, as are the duration and the frequency of the session throughout the therapy. Concerning more specifically the evaluation of PPPs, they have been empirically demonstrated to be effective for most psychiatric conditions. Several characteristics of PPPs are also specifically correlated with therapeutic effectiveness. Moreover, they produce long-term therapeutic effects, particularly concerning personality and after the end of the therapy. The qualitative and process-based evaluation of PPPs appears complementary to empirical evaluation, the latter suffering from several limitations (allegiance bias, indistinction of processes, questionable research practices, etc.) highlighted in particular by the recent crisis of reproducibility. The methodology of Randomized Controlled Trials should be associated with research based on clinical material. The approach of the Boston group, the analysis of psychotherapeutic processes with the Psychotherapy Q-Sort (PQS) and the modeling of the symbolization processes by the School of Lyon are three qualitative research paradigms that are particularly rich from this point of view. PPPs are effective for most psychiatric disorders in the short term, at the end of the therapy, and for several years afterwards. They generate lasting transformations in terms of the reduction of symptoms and of personality evolution. They often appear to be more effective than pharmacotherapy and lead to substantial savings when they are implemented in health care facilities for patients suffering from a large variety of pathologies. [ABSTRACT FROM AUTHOR]

Si l'intérêt pour la psychotraumatologie s'est progressivement généralisé au cours de la dernière décennie, faute de repérage diagnostique, de nombreux patients restent sans soins tandis que parallèlement, l'offre de psychothérapies différenciées s'est majorée. Notons également que si les recherches en neurosciences ont explosé en nombre, leurs applications concrètes utiles à la pratique quotidienne semblent plus ténues, notamment au plan pharmacologique. De tels achoppements seraient-ils causés par une prééminence de la référence au « stress » au détriment de la considération du « trauma » ? Au-delà des picrocholines querelles d'écoles, il apparaît aujourd'hui nécessaire de construire une nouvelle phase d'analyse. Nous exposons une revue critique de la littérature de langue anglaise avant de focaliser sur les quelques études francophones existantes. La majorité des études anglophones référencées se rattachent aux protocoles de deux travaux princeps sans que les paradigmes linguistiques en soutenant le design apparaissent très structurés. L'analyse linguistique s'y avère en fait limitée, sans mention des richesses apportées par les écoles de sémantique et de pragmatique. Il apparaît toutefois une lente complexification des méthodes d'analyse textuelle dans le temps. Pour l'espace francophone, seules deux études existent : l'une de Louis Crocq datant des années 1960, et une autre de Ribeton & Auxéméry mettant en évidence le syndrome psycholinguistique post-traumatique (anomie traumatique, répétitions linguistiques et désorganisation discursive). Les troubles psychiques post-traumatiques bénéficient d'un renouveau d'intérêt pour la psychiatrie et la psychologie contemporaines. La densification de la description du trouble de stress post-traumatique dans le DSM-5 pourrait encore se compléter des différentes formes cliniques spécifiques constituant les troubles psychiques post-traumatiques. Aussi, à l'heure où différents protocoles psychothérapeutiques apparaissent concurrents (protocoles comportementaux et cognitifs, traitements par l'hypnose, thérapies par mouvements oculaires, thérapies psychodynamiques, thérapies narratives, etc.), l'analyse de la restauration du langage pourrait permettre d'unifier une conception spécifique du traumatisme psychique et de ses conséquences cliniques. Le paradigme que nous proposons développe la recherche clinique à l'aide de marqueurs psycholinguistiques offrant d'évaluer l'efficacité des psychothérapies. Gradually emerging from the military medicine, interest in psychotraumatology has gradually become widespread over the last decade. Due to societal evolution, the consideration of post-traumatic psychic disorders is developing with psychopathological, neurobiological and even sociological conceptions. However, because of the clinical presentation of the psychic trauma and its clinical consequences, underdiagnosis and late diagnosis remain numerous. These suffering, intense and rich on symptomatic levels, appear most often blind concerning their psychotraumatic origins and therefore, without adapted therapeutic answer. However, many psychotherapeutic protocols have been deployed these last years from many theoretical references (behavioral and cognitive protocols, treatments by hypnosis, eye movement therapies, psychodynamic therapies, narrative therapies, etc.). It should be noted too that while the number of psychotraumatology research has exploded, the concrete evolutions useful for daily practice seem to be more tenuous, particularly in pharmacology. Would such a stumbling be caused by a pre-eminence of the reference to "stress" to the detriment of the consideration of "trauma"? Beyond the quarrels of schools, it now seems necessary to build a new phase of analysis. As it seems to us to constitute clinically what we call a "language injury", the psycholinguistic study appears as a space of heuristic research in order to explain the etiopathogenesis, the clinical presentations, and especially the offer of proposed care to patients suffering from post-traumatic stress disorder. If the linguistic theories have evolved a lot in the last fifty years, sometimes to the point of appearing contradictory, the tools generated today benefit from the development of logician's models and computing power. We present here a critical review of the literature of international works before focusing on the few existing francophone studies. Most referenced Anglophone studies relate to the protocols of two original works without the linguistic paradigms in supporting the design appear obvious. Linguistic analysis in fact turns out to be limited, without mentioning the wealth provided by schools of semantics and pragmatics. However, it appears a slow complexification of textual analysis methods over time. For the francophone space, only two studies exist: one from Louis Crocq dating from the 60s, and another from Ribeton & Auxéméry, more recent and for which we present a more exhaustive reading of the results. Post-traumatic psycholinguistic syndrome is here defined as a function of three symptoms: traumatic anomia, linguistic repetition and disorganised discourse. Traumatic anomia manifests in a quantitative reduction in discourse characterised by a lack of production, impaired verbal flow and lexical poverty. Linguistic repetition takes the form of phonological and syntactic repetition (verbal stereotypes, predilections, intrusions, perseverations and echophrasia). Phrasal and discursive disorganisation is characterised by time discordance, de-subjectivation (via indefinite and impersonal pronominal markers), and disfluency that can extend to agrammatism due to a lack of logical and chronological connectors. In order to better understand the nature and evolution of post-traumatic stress disorder, different language markers could be associated: length of production (number of words, number of letters per word, number of words per sentence, etc.), fields lexical (sensations, negative emotions, themes related to traumatic circumstances, etc.), qualities of language units (referencing to a word, an act, a movement, an idea, a sensation, etc.), syntactic structure (discursive disorganization, textual fragmentation, preeminence and discordance of time, logical inconsistencies, etc.), references to the self and others, capacities for synthesis or expansion of an idea (by dividing access to internal and external details). Ratios can be made, for example between the perceptive and cognitive terms, which would bring closer to the subjectivity. Finally, the notion of quality of transmitted information can be approached. Here, there is little consensus between studies on what is called "disorganization" and its "coherence". The verbal production may be different from the usual speech while keeping an organization of its own, even if it would be pathological and therefore isolated from the normal Gaussian or bimodal. As a rule, textual coherence and disorganization are analyzed from several linguistic markers (possible global understanding by others, adapted spatio-temporal contextuality, time matches, concordance of themes). Finally, the characterization of a single element seems insufficient: it appears necessary to study the links between emerging language markers. The understanding of post-traumatic psychic disorders benefits from a renewed interest in contemporary psychiatry and psychology. The densification of the description of post-traumatic stress disorder in DSM-5 could be further supplemented by the different specific clinical forms of post-traumatic stress disorder. But, for reasons inherent to the psychic injury, the post-traumatic symptoms remain most often marked by ineffability, post-traumatic symptom in itself which limits the diagnostic sensitivity referenced to the psychiatric symptomatology. From the systematic analysis of their discourse, we defined a new clinical approach to psychic injured patients: the post-traumatic psycholinguistic syndrome testifies to an injury of the language. Conversely, towards the care, it is the words which make it possible to be extracted from the revivals. At a time when different psychotherapeutic protocols may be concurrent (behavioral and cognitive protocols, hypnosis, eye movement therapies, psychodynamic and narrative therapies, etc.), the analysis of language restoration could unify a specific view of psychic trauma and its clinical consequences. Thus, while a new clinical model specific to psychic trauma should federate theoretical conceptions, our goal is primarily to better diagnose people suffering from post-traumatic stress disorder in daily practice. Also, the paradigm that we propose will develop research using psycholinguistic markers to evaluate the effectiveness of psychotherapies. [ABSTRACT FROM AUTHOR]

Psychological interventions have a long history of successful treatment of patients suffering from mental health and certain medical conditions. At the same time, psychotherapy research has revealed key areas of growth for optimizing patient care. These include identifying novel treatment delivery methods that increase treatment adherence, developing new strategies to more effectively address the ever-growing population of patients with comorbid conditions, and elucidating the mechanisms by which effective treatments work in order to further refine their design. Acceptance and commitment therapy (ACT) is an empirically supported psychotherapy that offers promise for patients suffering from a wide range of mental and physical conditions, while addressing these gaps and challenges in the field. ACT rests on the fundamental premise that pain, grief, disappointment, illness, and anxiety are inevitable features of human life, with the therapeutic goal of helping individuals productively adapt to these types of challenges by developing greater psychological flexibility rather than engaging in counterproductive attempts to eliminate or suppress undesirable experiences. This is achieved through committed pursuit of valued life areas and directions, even in the face of the natural desire to escape or avoid painful and troubling experiences, emotions, and thoughts. ACT is transdiagnostic (applies to more than one condition), process-focused, and flexibly delivered. In a relatively short period of time, ACT has been effectively implemented across a broad range of therapeutic settings, including mental health, primary care, and specialty medical clinics. ACT has also been delivered in a variety of formats, including 1-day group workshops, online and smartphone applications, and telehealth. Focus on how best to package and deliver treatment to meet the unique needs of different patient populations helps to ensure treatment adherence and has fostered successful application of ACT for patients in everyday clinical settings. [ABSTRACT FROM AUTHOR]

Therapist drift occurs when clinicians fail to deliver the optimum evidence-based treatment despite having the necessary tools, and is an important factor in why those therapies are commonly less effective than they should be in routine clinical practice. The research into this phenomenon has increased substantially over the past five years. This review considers the growing evidence of therapist drift. The reasons that we fail to implement evidence-based psychotherapies are considered, including our personalities, knowledge, emotions, beliefs, behaviours and social milieus. Finally, ideas are offered regarding how therapist drift might be halted, including a cognitive-behavioural approach for therapists that addresses the cognitions, emotions and behaviours that drive and maintain our avoidance of evidence-based treatments. [ABSTRACT FROM AUTHOR]

Abstract: Background: Over the years randomized controlled trials (RCTs) of various psychotherapies for treating depression have provided evidence to demonstrate the interventions’ efficacy/effectiveness. However, recent researches suggest that the quality of some RCTs were actually less than ideal, which could hence have biased their results. The present study aims to assess (1) the changes in characteristics of RCTs of psychotherapies for treating adult depression; (2) the temporal changes in their trial quality, and (3) the quality differences among different therapeutic approaches. Methods: We included 135 RCTs of psychotherapies treating adult depression published from year 1969 to 2011. Temporal changes in trials’ characteristics including their quantity and quality were assessed at study-level and arm-level. Quality differences among different schools of psychotherapy were assessed at arm-level. Results: Changes in quantity and improvements in methodological quality were found at study-level. Positive changes in trial quality at arm-level were observed in most aspects. Comparisons made across different schools of psychotherapy revealed statistically significant differences among them, with earlier behavior therapy trials doing worst and more recent third wave cognitive-behavior therapy doing best. Limitations: We could not determine whether the observed changes in quality resulted from actual improvement in trial quality and/or from improved reporting. The relatively smaller number of arms for several types of interventions could weaken the representativeness when making comparisons across psychotherapeutic approaches. Conclusion: Our study revealed positive temporal changes in both trial quantity and quality over the past five decades and has also spotted possible areas for further improvement. [Copyright &y& Elsevier]

Résumé: Dans les suites de la parution du décret du 20 mai 2010 réglementant l’usage du titre de psychothérapeute, deux enquêtes se sont intéressées au point de vue des étudiants et des enseignants sur la formation aux psychothérapies. L’une a été réalisée en 2010–2011 auprès des internes de psychiatrie, l’autre en 2012 auprès des PU-PH. Cet article résume les principaux résultats de ces enquêtes ayant déjà fait l’objet de publications, et les met en perspective avec les derniers articles internationaux traitant de la formation aux psychothérapies durant l’internat de psychiatrie. [ABSTRACT FROM AUTHOR]

Abstract: The therapeutic potential of reducing the risk of suicidal attempt repetitions has been widely studied in recent years, contributing to promote new techniques to reduce this risk. Yet still the question of indications and practical modalities of these techniques, as the subjects committing a suicide attempt are a heterogeneous population when considering their risk factors, diagnosis, and comorbidities. This work will aim to review randomized controlled trials, which have evaluated treatments for suicide attempt among suicidal patients, in that first part, and the sub-population at higher risk of patients with borderline personality disorder, in a second part. Several trials support the effectiveness of some interventions, ranging from simple (postcards, Green cards) to more structured ones. One of the main limitations seems to be the diversity of the population of suicidal patients. This review highlights the need to improve psychiatric assessment at the Emergency Department, targeting risk factors, and to develop specific care according to risk of repetition. [Copyright &y& Elsevier]

Abstract: In a first part, we presented the results of a literature review of these treatments among patients referred from the Emergency Department after a suicide attempt. As patients with borderline personality disorder have a significantly higher suicidality and as they deserve a special care for their special suicidal risk, we also reviewed the randomized controlled trials of treatments to improve the suicidality of such patients. Several trials support the effectiveness of structured interventions such as Dialectic and Behavioral Therapy, Mentalisation-Based-Treatment, Transference-Focused-Psychotherapy, Schema-Focused-Therapy, various cognitive-behavioral therapies, etc. However, one of the main limitations seemed to be the lack of study on patients with borderline personality disorder recruited in emergencies departments after a suicide attempt. This review highlights the need to better assess patients from the Emergency Services, by targeting risk factors, and to develop specific care according to risk of recidivism, and in particular to develop therapeutic modalities for acute suicidal patients with a borderline personality disorder. [Copyright &y& Elsevier]

Abstract: Resistance to psychopharmacological and psychotherapeutic therapies is a frequent difficulty clinicians are confronted to, with a frequency of 20 to 30 % concerning depression disorders. Other therapeutic approaches hence seem unavoidable to optimize treatments: structured psychotherapies such as behavioural and interpersonal therapies have shown their efficiency in anxiety and depression disorders, psychoeducational approaches help better observance in chronic pathologies. Biological and non medicinal approaches such as electroconvulsive therapy are still a therapy of reference for treating mood disorders and remain an indication for resisting schizophrenic disorders. [ABSTRACT FROM AUTHOR]

Abstract: The French Departments of Health and Research have just published the specifications for psychotherapy training. They accredit and guarantee the new – and the last? – stage in the development of psychotherapies, namely that of their “integration.” The latter is based on specific criteria: firstly, methodology: consider all currents, do not create a new system but incorporate methods in the “sequential treatment”: short therapy (about ten sessions), psychotherapy lasting one to two years, long analyses; secondly, epistemology: go beyond (meta-) specific school theories and find the common behaviors, cognitions, social environments, personalities, and unconscious processes; thirdly, clinical: connect methods and specific indications, this is the “pathology-therapy matching” and finally, pragmatism: attain the “nonspecific” factors which constitute 70% of the effectiveness of the therapy: the therapist''s personality, therapeutic alliance, reactions ranging from inter-subjectivity to attachment and transference. The authors propose a 4th degree integration which is not a new system but a new training approach (multidisciplinary team) to create a personal approach for each professional. [Copyright &y& Elsevier]

Abstract: This paper was initially presented during the scientific workshop of the French society for child and adolescent psychiatry and allied professions (SFPEADA), devoted to psychomotricity and its current bonds with child and adolescent psychiatry (Paris, September 29, 2005). The authors are a child and adolescent psychiatrist, using daily psychoanalytical psychotherapies in a universitary public hospital and two psychomotricians, who work in a child and adolescent public department, in a private activity and in a specialized institute (therapeutic, educational and teaching institute or ITEP). They present here the results of their clinical practices, exchanges and thoughts about a complex and discussed subject, which touches in more than one way with the bases of our clinical and therapeutic practices with children and adolescents: how do we choose the differential indications between psychotherapies and psychomotor therapies? [Copyright &y& Elsevier]

Abstract: Psychiatry is now confronting a critical movement, which predicts not only its « collapse », but also its « end » and even its « death ». After a reminder of the facts, this problem is approached by an analysis of the components and of the structure of psychiatry. First all the domains constituting psychiatry, their internal and external links, and their general coherence are reviewed. An analysis of psychiatry''s diverse components shows that the nature of mental trouble is not restricted to mental suffering only; it is also necessary to consider the role of biological factors, of representations, of the milieu, and of the tools for thinking, as well as that of the institutions and of the treatments which have evolved over time. Psychiatry is subsequently considered as a structure which has evolved from its roots, its conceptual evolution, and the crises it has overcome. It is thus possible to show the limits of present assertions and to deny the exclusive role of neurosciences or of sociology. The actual forms of psychiatry are certainly open to criticism, but this does not imply the disappearance of this discipline, the specificity of which rests not only on its objects of study, but also and especially on the nature of its procedures aiming at precising them more precisely. [Copyright &y& Elsevier]

Excitement appears to be the central axis of the personnality organisation for numerous children seen in consultation. Behind apparently opposite behaviours, going from a great agitation to an almost complete inhibition, the mecanisms are similar: they express theirs affects and psychical movementsat once, by theirs bodies and their motivity, by behaviors and not by mental working out, almost directly, without psychical elaboration. Before using words, these children need to experience, to live situation, emotion and by these experiences to be able to represent them to themselves. The excitation is not rejected but on the contrary, becomes the mainpivot of the treatment, being in the heart of the psychoanalytic work of group. Its main function is “to reanimate”, to lay out way to representation and symbolisation, i.e; the indispensable premonitory of the mind-mecanisms. The excitation used by the therapists, is not a cause of desorganisation, but permits the ego- structuration and the return to ambivalence. It is the only way to elaborate psychically a transition area witch can ensure a non collusion between fantasy and reality, and thus which can limit the resort to a kind of violence destroying wether the subject or the object. [Copyright &y& Elsevier]