French psychosomatic school

1. Introduction

Version followed: the Paris School of Psychosomatics (École psychosomatique de Paris) as transmitted by the Institut de Psychosomatique Pierre Marty (IPSO, Paris 13; clinical unit at the former Hôpital de la Poterne des Peupliers, now within ASM 13). That means the 1963 investigation interview (Marty, de M'Uzan and David), Marty's economic theory (operatory thinking, essential depression, progressive disorganisation, mentalisation, 1963–1991), his treatment rule "De la fonction maternelle à la psychanalyse" (from the maternal function to psychoanalysis), and the later IPSO work of Smadja (operatory life) and Szwec and Smadja (self-calming procedures). Psychosomatic relaxation is covered as an adjunct from the separate French psychoanalytic relaxation tradition (Sapir). It is not confirmed in IPSO primary sources that IPSO uses it routinely [uncertain].

What it is. This is a psychoanalytic theory of how psyche and soma are organised, with a matching style of assessment and psychotherapy for people with somatic illness, lesional or functional. It is not a manualised therapy. There is no session-by-session protocol. The founders described the concepts, the investigation and the therapist's function. Most of the concrete session guidance below comes from IPSO-trained authors and secondary teaching sources, or is my own synthesis, and is tagged as such [source: SPP, Paris School of Psychosomatics; IPSO presentation page; Béjaïa course resource].

How change happens. Somatic illness is understood economically. When excitation (from trauma, loss or overload) cannot be bound by mental representations (fantasy, dreams, affect, neurotic symptoms), it is discharged through behaviour or the body. If no regression stops it, this becomes a progressive disorganisation that can end in essential depression and serious illness. Change comes from restoring or building mentalisation: the quantity, quality, fluidity and permanence of representations, especially in the preconscious. The therapist first lends a protective "maternal" function: a shield against excitation (pare-excitation), or a source of excitation when there is too little. This lets regressions to fixation points, dream life, affect and fantasy return, so that excitation can be worked over psychically instead of somatically. Only after that does the work move, where possible, toward ordinary psychoanalytic interpretation [source: Béjaïa course resource; Sahraoui & Aoudia 2024 citing Marty; APAOR 2023 programme citing Marty/Racamier].

2. Framework

There are no formal manual phases. The sequence below combines the institutional practice described in the sources with the logic of Marty's "from maternal function to psychoanalysis" rule. Where a step is my own ordering, it is tagged [synthesis].

Phase 0: Referral and medical frame. Patients typically come through physicians who sense "something psychic" beyond the complaint. Historically, the School set out to answer questions from non-analyst hospital colleagues [source: Lassmann PhD, pp. 36–38, 44]. Goal: a shared frame with the treating physician, in which the psychosomatic work runs alongside medical care and never replaces it. Recommended practice: get consent to exchange information, name the treating physician and agree who to contact if the patient's somatic status changes. A brief written report after the investigation is common practice in hospital consultation, but IPSO's procedure for it is not stated [synthesis/uncertain].

Phase 1: Psychosomatic investigation (1–3 interviews). These are face-to-face, unstructured psychoanalytic interviews modelled on L'investigation psychosomatique (1963), which documented seven cases. Goal: assess mental functioning from an economic point of view, looking at all of the person's productions (speech, affect, dreams, behaviour, somatic history) together. That means the quality of mentalisation, operatory features, essential depression, fixation and regression points, the chronology of somatic episodes against life events, and current traumatic load. It is not a symptom-meaning hunt [source: Béjaïa course resource; Lassmann pp. 38–39]. In the founders' era, cases were discussed in a weekly team meeting with Marty [source: Lassmann p. 44]. Optional: a structured classification of the case using Marty's psychosomatic classification. It covers well, uncertainly and poorly mentalised functioning, behaviour neuroses, and the economic systems of apparent inorganisation, progressive disorganisation, global regression and partial regression [source: Béjaïa course resource]. The IPSO classification grid exists, but its items are not reproduced here [uncertain].

Phase 2: Indication and setting. Goal: match the setting to the patient's economy.

Face-to-face psychotherapy, 1–3 sessions a week, for serious illness, narcissistic insufficiency, operatory functioning or poor or uncertain mentalisation. This is the usual IPSO indication [source: Béjaïa course resource; Maupas 2015]. Historically, Marty's consultation at rue Falguière saw patients twice a week [source: Lassmann p. 44].
Couch, about 3 sessions a week, for benign somatisations in patients whose functioning is close to neurotic [source: Béjaïa course resource].
Who treats: IPSO's position is that these psychotherapies should be done by psychoanalysts with additional psychosomatic training [source: IPSO presentation page].
Adjunct: psychoanalytic relaxation, individual or group, when bodily experience is the only way in [uncertain as an IPSO standard; see 4.15].

Phase 3: Maternal-function phase (often long, from months to years). Goal: stop disorganisation, protect against excitation, revive affect and the preconscious, and allow regressions and the return of dreams. Criteria for moving on, which I have inferred from the stated goals [synthesis]: dreams are reported and can be associated to; affects are named and tolerated; the patient spontaneously links events to feelings; somatic episodes are fewer, or now come with psychic expressions such as anxiety or neurotic symptoms; the patient can manage separations (holidays, cancellations) without a somatic flare.

Phase 4: Toward psychoanalytic work. Goal: classical interpretation of conflict and transference, as functioning becomes more neurotic. This can include moving to the couch [source: the Marty rule as reported in the Béjaïa course resource]. The pace and criteria for this shift are clinical judgement and are not specified in the sources [uncertain].

Ending. Often done by gradually reducing session frequency. Some patients need indefinite, even sparse, contact, because stopping can set off somatic relapse [source: Béjaïa course resource]. Maupas reports an ending by mutual agreement, with the door explicitly left open [source: Maupas 2015].

3. Guiding principles

Economic point of view first [Béjaïa]. Before asking what a symptom means, ask how much excitation there is and where it is going: into the mind, into behaviour or into the soma.
The symptom is not a conversion message [SPP; Maupas 2015]. Do not decode somatic lesions symbolically. Their meaning is built in session, not dug up.
Mentalisation is the target [Marty via Sahraoui & Aoudia]. Assess and strengthen the quantity, quality, fluidity and permanence of representations, especially the preconscious.
"De la fonction maternelle à la psychanalyse" [Béjaïa; IPSO seminar title]. Start by being a protective, attuned object, and interpret only as much as the patient's functioning can bear.
Pare-excitation in both directions [Béjaïa]. Damp excess excitation when the patient is flooded, and supply excitation (interest, affect, play) when the patient is flat.
Regressions are protective [Marty, via Béjaïa]. Welcome partial regressions (dependence, neurotic symptoms, even passing anxiety) as stops on the way down. Do not rush to interpret them away.
Watch for progressive disorganisation [Béjaïa]. Track sequences: trauma or loss, then loss of affect and dreams, then operatory life, then somatic events. That sequence is a warning, and an interpretation is not the response.
Face-to-face as the default for fragile patients [Béjaïa; Maupas]. Seeing the therapist's face supports the patient's sense of an object. The couch and silence can be traumatic for poorly mentalised patients. That reasoning is mine [synthesis].
Shared affect (C. Parat's "affect partagé") [Béjaïa]. The therapist's own affective availability is a working tool, and the therapist's silences are measured parts of the setting.
Fit interpretation to functioning [Béjaïa]. Dialogue and playful or psychodramatic interpretation can get past operatory speech, where a deep interpretation would fall flat or disorganise.
Dreams protect [Béjaïa]. Bringing back dream life is a central aim, so ask about dreams and value them.
Prudence (Szwec on Marty: "the prudence of the mine-clearer") [Lassmann p. 42]. Move slowly near losses and defences that may be holding the economy together.
Offer yourself as a comparison, not a mind-reader (Marty: "But that is me, and I am not you") [Lassmann p. 42]. Lend your own affective reaction for comparison without telling the patient what they feel.
Countertransference as data [Maupas 2015]. Boredom, emptiness or a "white" relation in you show the patient's functioning. Do not act on them.
Medical care is primary and parallel [synthesis from Lassmann; IPSO]. Never interpret against medical treatment. Coordinate with physicians.
Specialised training [IPSO presentation page]. Psychoanalytic training plus psychosomatic training. Get supervision for operatory cases.
Continuity over termination ideals [Béjaïa]. Tapering, or an open door, may be safer than a clean ending.

4. Intervention inventory

The founders describe stances, functions and assessment methods. They do not give scripted techniques. Each item below states its basis. Example language is my own illustrative wording unless it is quoted and cited.

4.1 Psychosomatic investigation interview

Purpose / when: The first 1–3 meetings with any somatic patient. Assess the psychic economy and decide whether to treat and in which setting [source: Marty, de M'Uzan & David 1963, via Béjaïa course and Lassmann pp. 38–39].
Steps:
1. Sit face to face. Open with a minimal, non-directive invitation and let the patient organise the account.
2. Note the form of speech as well as its content: factual or associative, present-bound or historical, affect named or absent, and how the patient uses the relationship with you.
3. Intervene actively and with flexibility, varying what you do to test capacities. Offer a link, an affect word or a small provocation, and see whether the patient can take it up and elaborate. The founders' interviews varied the investigator's activity to suit each patient's economy. I have not checked the exact procedural detail in the 1963 text [uncertain].
4. Build a chronology of somatic episodes against life events: losses, moves, retirements, separations, births (see 4.2).
5. Ask about dreams, the nature of sleep, leisure and daydreaming, and childhood memories (see 4.3).
6. Watch your own experience of the relationship: emptiness, boredom, a sense of being met by a "double" (see 4.4).
7. Afterwards, write up the economy (mentalisation, regressions, current trauma) and discuss it with a team or supervisor if you can, as Marty's group did weekly [source: Lassmann p. 44].
Example language (illustrative): "Tell me what brings you, in whatever order it comes." / "When the illness started, what else was happening in your life?" / "And how was that for you?"
Watch for: Pushing toward insight too early can disorganise a fragile patient. An investigation that only collects medical facts has missed its point. Signs it is working: you leave with a clear picture of how this person handles excitation, not only a list of diagnoses.

4.2 Somatic–life chronology

Purpose / when: In the investigation and throughout treatment, to find disorganising traumas and fixation points [source: Béjaïa course on progressive disorganisation; synthesis for the procedure].
Steps: 1) Date each somatic onset or flare. 2) Ask what was happening in the months before: losses, role changes, the end of a sport or work activity (often a lost self-calming outlet, see 4.13). 3) Note whether affect, dreams or neurotic symptoms faded before the episode. 4) Keep the chronology in your notes and update it when new episodes occur.
Example language (illustrative): "Your first flare was in the spring after your father died. What was that year like?"
Watch for: Do not give the patient a causal theory ("your grief caused this"). That is the symbolic-meaning error and can provoke guilt. It is working when the patient starts making time links on their own.

4.3 Assessment of mentalisation and psychosomatic classification

Purpose / when: After the investigation. Decide on the setting and the dose of interpretation [source: Marty's classification, via Béjaïa; Sahraoui & Aoudia 2024].
Steps: Rate qualitatively:
- the quantity of representations (richness of associations, memories, fantasy);
- their quality and fluidity (can they link to affect, can they move);
- their permanence (are they available consistently, or do they collapse under stress). Then place the patient roughly as well mentalised (mental neurosis), uncertainly mentalised, or poorly mentalised (behaviour neurosis). Note any active progressive disorganisation or essential depression, and the regressions available. The IPSO grid gives a formal version, but its content is [uncertain].
Example language: none. This is a clinician's write-up.
Watch for: Mentalisation varies with circumstances, so reassess after life events. A poor rating is a reason for face-to-face maternal work, not for refusing treatment.

4.4 Recognising and staying with operatory thinking

Purpose / when: When speech is factual, present-bound and repetitive, "pauvre, répétitif et marqué du sceau de l'actuel et du factuel" [source: Béjaïa course paraphrasing Marty & de M'Uzan 1963]. Related features described by the founders are the relation blanche (a flat, blank relationship) and projective reduplication (the other is seen as a copy of oneself). Both are the standard account of Marty & de M'Uzan 1963 [uncertain on exact wording].
Steps:
1. Recognise it and do not fight it. It is a defence and a symptom of the economy, not resistance in the neurotic sense.
2. Stay interested in the concrete material: work, schedules, bodily facts. Your interest itself supplies excitation.
3. Look for small openings where affect or a detail with personal colour appears, and stay with them.
4. Show a difference between you and the patient, gently, to counter reduplication (see 4.8).
5. Avoid deep interpretations of unconscious meaning while the patient is in this mode [synthesis based on the principle of fitting interpretation to functioning].
Example language (illustrative): "You've described the schedule very precisely. I find myself wondering what it was like to be inside that day."
Watch for: Your boredom or sleepiness is information (see 4.14). It is working when a story slows down and the patient starts adding a feeling, a memory or a comparison.

4.5 Detecting essential depression and progressive disorganisation

Purpose / when: At every session with seriously ill or recently traumatised patients. Essential depression (first called "depression without an object") is a lowering of libidinal tone with no positive compensation and no self-reproach or psychic pain of the melancholic kind. Progressive disorganisation runs from the most evolved psychic layers, through the preconscious, to the somatic systems [source: Béjaïa course; APAOR 2023 citing Marty]. Racamier, quoting Marty, calls it a silent "déflation" of psychic life [source: APAOR 2023].
Steps:
1. Track markers from session to session: dreams disappearing, affect flattening, interests narrowing, more operatory speech, more behaviour (overwork, compulsive exercise).
2. When they appear, increase the maternal-function supply: more presence, more interest, perhaps more sessions [synthesis].
3. Tell the treating physician that you are worried about vulnerability, with consent [synthesis].
4. Screen for ordinary depression and suicide risk with standard risk-assessment procedures. Essential depression can coexist with, or be mistaken for, other depressions [synthesis].
Example language (illustrative): "You've told me a lot about tasks lately and very little about you. Things seem to have gone quiet inside. I'd like us to meet more often for a while."
Watch for: The absence of complaint is the signal. Sources do not offer a separate technique for reversing it. What they offer is the maternal function (4.6–4.7) and support for regressions (4.12).

4.6 Maternal function I: protective shield (pare-excitation)

Purpose / when: When the patient is flooded by excitation from trauma, medical news or overwhelming events. The therapist shields, as a mother's function does for an infant [source: Béjaïa course; Maupas 2015 on the failed maternal shield].
Steps: 1) Keep the frame very regular: same times, same room, advance notice of absences. 2) Slow the pace. Summarise, order and put into words what is happening. 3) Do not add new stimulation, such as deep or confronting interpretations. 4) Name what is happening in simple terms, to contain it.
Example language (illustrative): "A lot has hit you at once: the diagnosis, the move, your daughter leaving. Let's take one piece at a time here."
Watch for: Giving too much reassurance can shut down affect. It is working when the patient arrives calmer and can stay with one theme.

4.7 Maternal function II: supplying excitation and introducing affect

Purpose / when: When the patient is flat or operatory and "under-excited". The therapist brings in excitation [source: Béjaïa course]. Maupas describes questions and links offered "afin d'introduire de l'affect" (to introduce affect), and gives the example of asking whether the patient might miss her mother during a separation [source: Maupas 2015 p. 65].
Steps: 1) Pick concrete moments in the narrative. 2) Offer a plausible affect as a question, not a statement. 3) Use liveliness: tone, curiosity, light humour. 4) If the patient takes it up, stay there. If not, drop it without pushing.
Example language (illustrative): "Ten days without seeing her. Could you miss her a little?" / "Some people would be furious at that. What about you?"
Watch for: Imposing feelings on the patient, or doing all the mentalising yourself so the patient never takes it over. It is working when the patient corrects or refines your proposed feeling, which is a sign of their own representing.

4.8 Offering the therapist's own reaction as a point of comparison

Purpose / when: To introduce difference and an affective model without telling the patient what they feel. This counters reduplication, where the other is experienced as identical to oneself. Szwec recalls Marty telling a patient "But that is me, and I am not you" [source: Lassmann p. 42].
Steps: 1) Say your own likely reaction in the first person. 2) Mark straight away that it is yours, not theirs. 3) Leave room for the patient to differ.
Example language (illustrative): "In your place I think I'd have been hurt. But that's me. How was it for you?"
Watch for: Self-disclosure about your personal life is not what is meant. Keep it to an affective reaction to the material. It is working when the patient answers with a reaction that is different from yours.

4.9 Shared affect and measured silence

Purpose / when: Throughout face-to-face work. C. Parat's affect partagé (shared affect) means the therapist and patient have affects and representations available in common. The therapist's silences are part of the setting [source: Béjaïa course on Parat].
Steps: 1) Let your affective resonance show, in your face and voice. 2) Keep silences short and "inhabited", so the patient can see that you are present and attentive. 3) Break silences that turn blank or anxious with a simple relaunch [synthesis on dosage].
Example language (illustrative): (after a pause) "I'm still with what you said about the hospital corridor."
Watch for: Long analytic silence can be experienced as abandonment by operatory patients and may be followed by somatic events [synthesis]. It is working when silences become thinking time, not dead time.

4.10 Dialogue and playful or psychodramatic interpretation

Purpose / when: When operatory discourse blocks classical interpretation. Dialogue and a playful, psychodramatic style can short-circuit it [source: Béjaïa course].
Steps: 1) Take a concrete scene the patient has described. 2) Stage it lightly: voice what a character might be thinking or saying, or exaggerate a little with humour. 3) Invite the patient to correct or play along. 4) Do not turn it into an interpretation of deep unconscious content.
Example language (illustrative): "So your boss walks in and, if he spoke his mind, might say: 'Not you again!' What would you have answered, in your head?"
Watch for: Mockery, or a playfulness the patient cannot share. Respect the patient's level. It is working when the patient laughs, adds lines, or brings a fantasy.

4.11 Inviting and valuing dreams

Purpose / when: At every stage. Reviving dream life is a central goal because dreams protect the psychosomatic balance [source: Béjaïa course].
Steps: 1) Ask regularly and without pressure whether the patient has dreamt. 2) Welcome any fragment, even a vague image or a nightmare, with interest. 3) Early on, take up the dream's existence and its affect before interpreting its meaning. 4) Later, as mentalisation grows, invite associations and interpret in the usual way [synthesis on staging].
Example language (illustrative): "Even a scrap of a dream interests me. Anything this week?" / "Just that image of a closed door. What does it bring to mind?"
Watch for: Interpreting the first dreams too quickly may discourage them [synthesis]. It is working when dreams become more frequent and richer, and when the patient brings them unprompted.

4.12 Supporting regressions and fixation points

Purpose / when: When a regressive move appears: dependence on the therapist, a new neurotic symptom, anxiety, a return to an old interest. In Marty's model, a regression to a fixation point stops progressive disorganisation [source: Béjaïa course on Marty's regression/disorganisation].
Steps: 1) Recognise the regression as protective. 2) Tolerate dependence, such as extra contacts or the need to see you, within a stable frame. 3) Don't interpret it away or push the patient toward "autonomy" too early. 4) Track whether somatic activity falls when the regression appears.
Example language (illustrative): "You've been more anxious this month, and that's hard. I also notice the skin flares have quietened. Let's give the worry room here."
Watch for: Mistaking a protective regression for deterioration. Psychiatric risk (suicidality, psychosis) still needs standard assessment. It is working when psychic symptoms take the place of somatic ones.

4.13 Working with self-calming procedures (procédés autocalmants) and behaviour

Purpose / when: When the patient relies on repetitive, often motor or effortful activity to get calm, as distinct from satisfaction: punishing sport, overwork, compulsive routines. Szwec described such patients as "voluntary galley slaves", linked to early imbalances between mother and child [source: Lassmann p. 7 on Szwec 1998]. The concept comes from Smadja and Szwec's IPSO work and draws on Fain's distinction between a calming mother and a satisfying mother [source: Smadja & Szwec 1993; Fain 1971, uncertain on detail].
Steps: 1) Map the behaviours and when they increase: after losses, conflicts or excitation. 2) Don't prohibit them or interpret them as pleasure-seeking. 3) Notice what happens when the outlet is blocked (injury, retirement, illness), since that can be a disorganising trauma (see 4.2, 4.5). 4) Gradually invite representations around the activity: what goes through the patient's mind, what it calms.
Example language (illustrative): "You run until you're empty. What would be there if you didn't?" / "Since the knee injury stopped the running, how have you been handling the evenings?"
Watch for: Losing the outlet can bring a somatic episode, so increase support at that point. It is working when the patient can put the excitation into words and feel it as anxiety or anger instead of discharging it straight away.

4.14 Using countertransference, including the "white" relation

Purpose / when: Continuously. Maupas uses countertransference to bear the patient's swings between factual and associative speech, and between fantasy and reality [source: Maupas 2015 p. 59]. Lassmann reports the investigators' sense of a static, fragmented relationship in which the patient seems to bring the interlocutor down to their own somatic level [source: Lassmann p. 38].
Steps: 1) Notice boredom, sleepiness, irritation, emptiness or bodily sensations in yourself. 2) Treat them as information about the patient's economy, not as failure. 3) Turn them into maternal-function moves: re-engage and bring in some liveliness (4.7). 4) Take persistent reactions to supervision.
Example language: none. This is internal work. If you voice it, do so only in a softened, first-person way (see 4.8).
Watch for: Acting out your boredom (cancelling, cutting sessions short) or rescuing through over-activity. It is working when your own interest becomes alive again during the session.

4.15 Psychoanalytic (psychosomatic) relaxation, as an adjunct

Status: Not confirmed as a standard IPSO technique in the sources [uncertain]. The French psychoanalytic relaxation method associated with Michel Sapir (a physician at the Rothschild hospital, who adapted Schultz's autogenic training) aims at access to the unconscious through bodily and psychic work, listening and sensory linking. Its aim is not well-being as such [source: Santé mentale 2023 on Sapir; Sapir's own texts not drawn on]. A published hospital group protocol for cancer patients uses four phases per session: muscular relaxation, concentration on an image, return, then verbalisation [source: Thibault-Engel & Braud-Lencou 2014].
Purpose / when: For patients who cannot yet use words about inner states and for whom the body is the only accessible channel. Also for medically burdened patients who need a contained space [synthesis].
Steps (from the group protocol above, adapted for individual use [synthesis]): 1) Hold a preliminary interview to check suitability and agree a contract for a set number of sessions. 2) Patient lying or seated. Use a calm voice to induce attention to parts of the body, heaviness and breathing. 3) Invite a simple image or sensation. 4) Bring the patient back gradually (stretching, eyes open). 5) Spend time on verbalisation: what was felt, imagined or remembered. This is the psychoanalytic core of the method. Use touch only if you are trained in a relaxation method that includes it and the patient has given explicit consent [synthesis].
Example language (illustrative): "Let your attention go to your right arm … just notice what's there." Afterwards: "What came to you during the relaxation, a sensation, an image, a memory?"
Watch for: Anxiety or depersonalisation on relaxing, and memories of medical procedures coming back. Stop and talk if they appear. It is working when the verbalisation phase gets longer and richer and bodily sensations take on representations.

4.16 Managing separations and somatic events within the treatment

Purpose / when: Holidays, cancellations, hospital stays, the therapist's absences, or a somatic flare during treatment. Separation is a classic disorganising trauma [synthesis based on the disorganisation model; Maupas 2015 on endings that repeat separation].
Steps: 1) Announce your absences well ahead and talk about them more than once. 2) Offer continuity where appropriate (a phone contact, or a session before and after). 3) When the patient has a somatic event, look at the timing against the frame and the patient's life, and pick up what was happening without imposing a causal link. 4) If the patient is hospitalised, keep the bond going (a call, a visit if the setting allows), within your frame and with consent [synthesis].
Example language (illustrative): "I'll be away for the two weeks of August. We'll talk about it again, because last summer was a hard one."
Watch for: Flares after breaks, and missed sessions just before them. It is working when the patient can feel and say that they miss you, or are angry, instead of only falling ill.

4.17 Transition toward interpretive psychoanalytic work

Purpose / when: When mentalisation has strengthened. The second part of Marty's rule is moving "… à la psychanalyse" [source: Béjaïa course].
Steps: 1) Check the markers in Section 2, Phase 3. 2) Begin interpreting transference and conflict in measured doses, watching for somatic reactions in the following days. 3) Decide on any move to the couch or more sessions together with the patient. Keep face-to-face if somatic fragility persists [synthesis on the procedure; the indications come from the Béjaïa course].
Example language (illustrative): "It seems that when I set a limit you go quiet, as you did with your father."
Watch for: A somatic flare after interpretive steps means you should step back to maternal-function work. It is working when interpretations are taken up and elaborated without somatic cost.

4.18 Ending: tapering and the open door

Purpose / when: At the end of treatment [source: Béjaïa course; Maupas 2015].
Steps: 1) Reduce frequency gradually, from weekly to fortnightly to monthly. 2) Explicitly offer the option of coming back. 3) For some patients, plan indefinite sparse follow-up, because stopping can bring relapse [source: Béjaïa course]. 4) If the patient announces an abrupt ending, explore whether it repeats an earlier separation, and allow postponement [source: Maupas 2015].
Example language (illustrative): "We can space our meetings out, and the door stays open."
Watch for: A flare after each reduction in frequency means you should slow the taper.

4.19 Coordination with medical care

Purpose / when: From referral onward. The School grew out of answering hospital physicians' questions, and patients reach it through doctors [source: Lassmann pp. 36–38, 44]. The specific steps below are my own synthesis, since IPSO's liaison procedure was not found [synthesis].
Steps: 1) Get written consent to communicate with the named physicians. 2) After the investigation, send a short note. It should state what you assess (mental functioning and vulnerability, without technical jargon or intimate content) and the setting proposed. 3) Agree how to signal concerns both ways: signs of disorganisation from you, medical changes from them. 4) Never advise on medication or medical decisions, and never present psychic factors as an alternative to treatment. 5) Encourage the patient to follow medical care, and explore any refusals in therapy.
Example language, to a physician (illustrative): "Mr X is seen weekly. I note a recent flattening of his affective life after his retirement. I'd value hearing of any change in his somatic course."
Watch for: The patient splitting "mind doctor" from "body doctor". The therapy being seen as "one more medical prescription", as Maupas's patient experienced it [source: Maupas 2015 p. 60]. Talk about that experience with the patient.

5. Handling problems

The primary sources say little about problem management. Items without a source tag are my own synthesis, built on the School's principles, and are marked [synthesis].

"Stuck": endless factual, operatory speech. Expect it; it is the clinical picture, not an impasse [source: Béjaïa course on operatory thinking]. Response: increase your liveliness and interest in the concrete (4.4, 4.7). Use playful or dramatised dialogue (4.10). Ask about dreams regularly (4.11). Measure progress in small units, such as one affect word or one memory per session [synthesis].
"Resistance" that is really a defence of the economy. Refusing to talk about feelings may protect a fragile balance. Response: don't confront it. Use Szwec's "mine-clearer" prudence [source: Lassmann p. 42]. Keep interpretation for when mentalisation has grown (4.17) [synthesis].
Overwhelm: an acute trauma or diagnosis floods the patient. Response: switch to pare-excitation (4.6). Simplify, order and slow things down. Consider extra sessions. Screen for suicide risk and acute psychiatric risk using standard risk-assessment procedures, and refer to crisis services where indicated [synthesis].
Essential depression or signs of progressive disorganisation. Response: more frequent contact, increased maternal function, active support for any regression (4.5, 4.12), and an alert to the physician with consent (4.19) [synthesis built on the Béjaïa course model].
Somatic flare after an interpretation, a break or a step forward. Read it as an economic signal. Step back to maternal-function work, look at the timing, and avoid causal blame (4.2, 4.16, 4.17) [synthesis].
Non-adherence: missed sessions, sporadic attendance. For operatory or behaviour-neurosis patients, the frame itself may be hard to hold psychically. Response: keep the frame stable and get in touch after missed sessions without punishing. Consider a lower but more reliable frequency. Explore whether attendance follows symptom relief, with the patient coming only when ill [synthesis].
Non-adherence to medical treatment. Do not side with the refusal or take over the physician's role. Explore the meaning of the refusal and inform the physician with consent (4.19) [synthesis].
"My problem is physical. Why am I here?" The patient sees therapy as "une prescription médicale de plus" (one more medical prescription) [source: Maupas 2015 p. 60]. Response: don't argue psychogenesis. Present the sessions as a place to talk about living with the illness and what goes on around it [synthesis].
Ruptures: the patient announces an abrupt ending. Explore it as a possible repetition of earlier separations. Allow postponement. Agree an open door [source: Maupas 2015]. Taper rather than stop if you can (4.18).
Ruptures through therapist enactment: boredom, cutting sessions short, over-activity. Monitor countertransference (4.14). Use supervision. Repair openly if it was noticed [synthesis].
Self-calming behaviours escalate or are suddenly lost. Don't prohibit them. Watch for disorganisation when the outlet is lost, increase support, and work on putting the excitation into words (4.13) [synthesis drawing on Szwec, via Lassmann].
Patient demands symbolic explanations ("what does my ulcer mean?"). The School does not decode lesions as conversion messages [source: SPP; Maupas 2015]. Response: be curious about the question itself and about what was happening around onset, without supplying a meaning [synthesis].
Therapist pulled into medical decisions. Decline. Redirect to the physician. Keep coordinating (4.19) [synthesis].
Couch requested too early by a fragile patient. Keep face-to-face while somatic fragility or poor mentalisation lasts [source: Béjaïa course indications], and explain why in terms of being together in the work [synthesis].
Relaxation triggers anxiety or medical memories. Stop the induction, return to talking, and reconsider whether relaxation is indicated (4.15) [synthesis].
Therapist without psychosomatic training. IPSO holds that this work needs psychoanalytic and psychosomatic training [source: IPSO presentation page]. Seek supervision or referral for seriously ill or operatory patients [synthesis].

Sources

Sources:

Further reading (not drawn on; standard references) [uncertain where used for detail]:

Marty P., de M'Uzan M., David C. (1963). L'investigation psychosomatique. PUF.
Marty P., de M'Uzan M. (1963). La pensée opératoire. Revue française de psychanalyse, 27 (special issue).
Marty P. (1966). La dépression essentielle. Revue française de psychanalyse, 32.
Marty P. (1976). Les mouvements individuels de vie et de mort. Payot.
Marty P. (1980). L'ordre psychosomatique. Payot.
Marty P. (1990). La psychosomatique de l'adulte. PUF (Que sais-je ?).
Marty P. (1991). Mentalisation et psychosomatique. Les Empêcheurs de penser en rond.
Fain M. (1971). Prélude à la vie fantasmatique. Revue française de psychanalyse, 35.
Smadja C., Szwec G. (eds) (1993). Les procédés autocalmants. Revue française de psychosomatique, 4.
Szwec G. (1998). Les galériens volontaires. PUF.
Smadja C. (2001). La vie opératoire. PUF (English translation: The Psychosomatic Paradox, 2005).
Parat C. (1995). L'affect partagé. PUF.
Aisenstein M., Rappoport de Aisemberg E. (eds) (2010). Psychosomatics Today: A Psychoanalytic Perspective. Karnac.
Lassmann W. (2022). Lost to Desire: The École Psychosomatique de Paris and its Encounter with Psychosomatic Illness. Routledge.

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