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Cognitive Optimisation and Schizophrenia: Assembling Heterogeneity, Overcoming the Precariousness of Life, and Challenging Public Health Policies in Psychiatry in France

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Abstract

Cognitive remediation therapy (CRT) aims to optimise cognitive abilities of people who suffer from schizophrenia in order to improve their social adaptation. This therapeutic orientation was developed in psychiatry in the 1980s and 1990s, at a time when the disorder was being redefined as a neurocognitive deficit disorder. In this article, I describe CRT as an assemblage that lies at the intersection of multiple, overlapping theories and spaces of mental disorders and psychiatric care. To do so, I draw on 18 months of ethnographic research conducted in a French hospital unit dedicated to the development of CRT. I argue that the focus on cognitive health and cognitive abilities (or deficits) is not only redefining the logics of care and reshaping medical conceptualisations of schizophrenia, but it is also opening up to a new understanding of people’s precarious life conditions, where emotional, biological, and cognitive fragility is intertwined with social and economic uncertainty. I then examine the extent to which psychiatrists have extended the goals of CRT to include psychosocial rehabilitation in order to mitigate not only the effects of cognitive deficits, but also the effects of limited social and professional integration encountered by patients. Finally, I conclude with a consideration of how CRT has become, for its proponents in France, a means to develop a policy and organisational project for French psychiatry.

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Notes

  1. Depending on the psychiatrists, CRT aims to “enhance”, or “improve” cognitive functions. CRT is also known as “cognitive enhancement therapy” or “cognitive rehabilitation therapy”.

  2. The terms in inverted commas (excepting publications quotations) are terms used in the vernacular by the actors.

  3. For Ehrenberg, the ideal of the man/woman of action of the cognitive sciences who acquires confidence through exercise and repetition or rehearsal should be understood in the light of the ideal of the psychoanalytic “examined life” and the practices of elaboration of discourse to give meaning to life (Ehrenberg 2020).

  4. Two examples among others: “Home exercises are useful to promote the transfer of strategies to daily life and their subsequent automation” (Peyroux and Franck 2014:8). “The neurocognitive training consists of computerized exercises collaboratively performed by patient dyads, and the group-based social cognitive training centers on learning exercises that lead the individual to process social information in an automatic, ‘gistful’ way” (Fiszdon and Reddy 2012:736).

    CRT principles are based on the “drill-and-practice” method, a learning and teaching strategy “rooted in the theory of behaviorism” characterised by disciplined systematic repetition and exercises (Lim, Tang and Kor 2012).

  5. For instance, the 2019 edition of the CRT unit annual workshop was entitled “Rehabilitation: a paradigm shift in society”.

  6. I will not discuss this point, but the position of the nurses in the unit towards the term “coach” was ambivalent. It was for instance criticised for denying, to their mind, the therapeutic dimension of their work. But they were also able to appropriate it to valorise the intensity and inventiveness of the care they provided, and their considerable implication in the management of the lives of their “patients” (the term they used) as was the case for Camille with Mme B, or again the quality of the relationships established with them (distinguishing themselves from the supposed distance required in a patient/therapist relationship).

  7. My translation from French.

  8. Nicolas Franck is a French psychiatrist and cognitive science researcher. He is the most prominent figure in CRT in France and a prolific author on the subject. He founded and presides the French Society of Cognitive Remediation and was the instigator of a CRT diploma. This all aimed to disseminate and promote the technique in the medical world. He was also the founder and directs the resource centre for psychosocial rehabilitation and cognitive remediation at the Centre Hospitalier Le Vinatier. He has been consulted or was involved in several recent institutional reports on the organisation of the French mental health system, where CRT has a fairly prominent place (see: Centre de Preuves en Psychiatrie et en Santé Mentale 2015; Laforcade 2016).

  9. My translation from French.

  10. See also: https://centre-ressource-rehabilitation.org/.

  11. The “war” refers explicitly to the national controversy that started in France in 2004 in the mental health field in reaction to two institutional evaluation reports on the behavioural disorders in children and adolescents and the efficacy of psychotherapies. To sum up too briefly, it has opposed proponents of psychodynamics and psychoanalysis against the cognitivists and biological psychiatrists (see Champion 2008). It should be noted that in France, CRT is identified as a form of cognitive and behavioural therapy, inherited from cognitive neuroscience and biological psychiatry.

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Funding was provided by Mission pour l’Interdisciplinarité du Centre national de la recherche scientifique « Innovations thérapeutiques pour les maladies mentales ».

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  1. CNRS – Lesc, Laboratoire d’ethnologie et de sociologie comparative (CNRS UMR 7186, Université Paris Nanterre), Maison Archéologie & Ethnologie René-Ginouvès, 21, allée de l’université, 92023, Nanterre Cedex, France

    Baptiste Moutaud

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Moutaud, B. Cognitive Optimisation and Schizophrenia: Assembling Heterogeneity, Overcoming the Precariousness of Life, and Challenging Public Health Policies in Psychiatry in France. Cult Med Psychiatry 46, 710–738 (2022). https://doi.org/10.1007/s11013-021-09745-2

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