Renne Nunes

Notes on the “Non-Recommendation” of Psychoanalysis

I. Introduction: Guidelines, Evidence, and Singularity

The recent position of the Haute Autorité de Santé (HAS) classifying psychoanalysis as “not recommended” in the field of Autism Spectrum Disorder (ASD) (Haute Autorité de Santé [HAS], 2026a) reopens a discussion that extends beyond the technical domain of clinical guidelines. Although such wording does not constitute a legal prohibition nor a formal invalidation of psychoanalytic practice, its symbolic and institutional force reorganizes professional legitimacy, training frameworks, and social expectations regarding what is to be recognized as legitimate care.

The debate that emerges cannot be reduced to a simplistic opposition between “science” and “non-science,” nor to a corporate defense of psychoanalysis. Rather, it requires examining the epistemological assumptions that underpin contemporary validation criteria and interrogating the ethical consequences that arise from the hegemony of particular methodological models in the formulation of public policy.

Evidence-Based Medicine (EBM) has consolidated itself over recent decades as the dominant paradigm, privileging controlled clinical trials, statistical replicability, standardized outcome measures, and population-level predictability. These criteria are coherent with the function of a public health regulatory body: to guide large-scale decisions based on comparable and scalable data (HAS, 2026a, 2026b).

However, acknowledging the legitimacy of this model does not entail assuming its absolute neutrality. As Kuhn (2013) demonstrated in his analysis of scientific paradigms, every field operates within assumptions that delimit what counts as a legitimate problem, an acceptable method, and valid evidence. What qualifies as proof is never independent of a theoretical framework.

In this sense, the classification of psychoanalysis as “not recommended” in the treatment of ASD should not be interpreted merely as an empirical determination of inefficacy, but as the result of applying a specific evaluative model to a practice whose nature does not fully align with that model’s criteria.

The question, therefore, is not whether the HAS acts in bad faith, but whether the methodological scope it adopts is capable of encompassing dimensions of care that exceed standardized measurement, particularly when dealing with psychic suffering, the constitution of social bonds, and subjective experience.

At this point, the debate ceases to be merely technical and becomes epistemological and ethical.

II. Paradigms, Incommensurability, and the Clinical Method

Discussions regarding the scientific status of psychoanalysis often revolve around its alleged inability to meet criteria of falsifiability or experimental replicability. While such critiques are relevant within the natural sciences, they become less straightforward when transposed into the realm of human and clinical sciences.

Kuhn (2013) demonstrated that science does not progress through simple linear accumulation of data, but through paradigm shifts — conceptual structures that determine what counts as a legitimate problem, method, and solution. Distinct paradigms are not merely competing theories; they are often incommensurable, operating with different languages, assumptions, and validation criteria.

Evidence-based medicine currently constitutes the dominant paradigm in public health policy. Its horizon is population-based, comparative, and statistical. Psychoanalysis, by contrast, is situated within an interpretative clinical paradigm centered on singularity and the dynamics of transference. The object of one does not coincide with the object of the other.

Incommensurability here does not imply irrationality, but rather a difference in framing. Evaluating a singular clinical practice according to metrics designed for standardized interventions may produce a structural misalignment between method and purpose.

In this regard, the work of Fulgencio (2008) is particularly illuminating. In discussing Freud’s speculative method, Fulgencio argues that psychoanalysis does not operate through statistical generalization but through situated clinical interpretation. Its regime of validation is clinical-hermeneutic, grounded in the internal coherence of the analytic process and in its transformative effects on the analysand’s experience.

This does not mean that psychoanalysis lies outside the domain of rationality. It simply means that its validation regime differs. To conflate methodological difference with lack of rigor is a categorical error.

Thus, the tension does not reside in an opposition between science and non-science, but in the coexistence of distinct epistemological models. The problem emerges when one paradigm becomes hegemonic to the extent that it defines as illegitimate practices that do not conform to its own criteria.

In the case of autism, this tension intensifies. The developmental-behavioral paradigm operates through observable and measurable indicators of skill acquisition. Psychoanalytic clinical practice, by contrast, engages with transformations in psychic economy, relationships to desire, the management of anxiety, and the constitution of symbolic bonds. Dimensions whose measurement is far from straightforward.

The risk is not that one approach replaces another, but that methodological hegemony reduces the field of care to what can be protocolized.

III. The Performativity of Guidelines and the Professional Field

Healthcare guidelines are not merely technical summaries of scientific literature. They are institutional acts with performative effects. By classifying an approach as “not recommended,” a regulatory body does more than report on the state of evidence according to its methodological criteria; it reorganizes the field of legitimate practices.

The symbolic authority of an institution such as the Haute Autorité de Santé grants its formulations a weight that exceeds technical wording. In public reception, “not recommended” tends to be translated as “ineffective,” “outdated,” or even “inappropriate.” This simplification does not necessarily stem from flawed institutional drafting, but from the dynamics of discursive circulation in social and media contexts.

The effect is not neutral. In concrete terms, guidelines influence:

• public funding policies
• service accreditation
• university training and clinical residencies
• family expectations
• professional reputation

Even when wording does not explicitly prohibit or formally disqualify a practice, it may produce a gradual displacement of legitimacy.

This phenomenon is not unique to psychoanalysis. It is a structural mechanism of evidence-based policy: what is not recommended tends to lose institutional space, regardless of its historical presence or cultural relevance.

There is therefore an ethical dimension to the formulation of guidelines. Methodological clarity is indispensable, but so too is communicative precision. When technical classification does not explicitly distinguish between “not evidenced according to specific criteria” and “ineffective,” reductive interpretations become likely.

In the field of autism, this distinction is particularly delicate. ASD involves not only the acquisition of functional competencies, but psychic suffering, identity construction, relationships to others, and symbolic inscription. When the debate is confined to protocolized interventions, the very imagination of care risks becoming narrowed.

This does not imply advocating automatic equivalence among approaches. It means recognizing that public policy operates at a population level, whereas clinical practice, especially psychoanalytic practice, operates at the level of singularity.

When institutional discourse fails to clarify this difference in scope, an unintended consequence may follow: the assimilation of therapeutic plurality into an implicit hierarchy of ontological validity.

The central issue is not the substitution of one model by another, but the balance between regulatory orientation and preservation of clinical complexity.

IV. Autism, Subjectivation, and the Psychoanalytic Tradition

Contemporary debates on ASD interventions are often structured around measurable indicators of skill acquisition. Yet the psychoanalytic tradition has developed a field of inquiry that shifts the focus from behavioral correction to psychic organization and singular modes of relational constitution.

Klein (1930) introduced the centrality of primitive unconscious phantasy in psychic constitution. Tustin (1992) explored “autistic phenomena” as specific forms of sensory encapsulation and defense against annihilatory experience. Winnicott (1982) emphasized the role of a facilitating environment in the integration of the self.

Maleval (2017) proposed understanding autism as a singular mode of relation to the signifier and to the Other, suggesting that certain behavioral manifestations may function as structuring subjective solutions.

Ogden (1994) developed the notion of the “analytic third,” expanding the understanding of clinical space as co-created psychic experience. Green (1999) offered conceptual tools to think states of psychic withdrawal and negativity that cannot be reduced to functional deficits.

In the Brazilian context, Korbivcher (2010), drawing on Bion’s framework, emphasized emotional transformation processes and the containing function in autistic states. Mélega (2024) contributed consistent clinical reflections on symbolization and psychic destinies in post-autism narratives.

These authors do not form a homogeneous block nor claim therapeutic exclusivity. What unites them is a clinical ethic: the autistic subject cannot be reduced to observable behaviors nor to adaptive performance criteria.

The crucial distinction here is not between “effective” and “ineffective,” but between adaptation and subjectivation. Adaptation refers to operating according to environmental expectations. Subjectivation concerns the possibility of assuming a singular position in relation to language, desire, and social bonds.

A care policy that privileges functional indicators alone risks rendering subjective experience invisible. Conversely, a clinical practice that disregards the concrete demands of social insertion would also be insufficient.

V. Science, Pluralism, and the Ethics of Incompleteness

The debate regarding psychoanalysis in the field of autism cannot be resolved through the mere invocation of methodological criteria nor through passionate defense of clinical traditions. It requires a broader reflection on the status of scientific knowledge and on the inherent limits of any dominant paradigm.

Kuhn (2013) showed that science is structured by disciplinary matrices that delimit legitimate problems and acceptable methods. Paradigms are not neutral; they are historical structures of intelligibility. This does not invalidate them, but it prevents their being mistaken for the totality of reality.

Evidence-based medicine today represents a robust and effective paradigm in many domains of health. Its commitment to measurement, replicability, and population predictability responds to legitimate demands of public accountability. To deny its relevance would be conceptually misguided.

The risk lies not in the existence of a dominant paradigm, but in its transformation into an exclusive criterion of ontological legitimacy.

When only what is measurable is considered real, the field of care risks being reduced to what can be quantified. Yet human experience is not exhausted by observable indicators. Suffering, anxiety, identity, and belonging are not secondary epiphenomena; they are central dimensions of existence.

Psychoanalysis does not claim epistemological immunity nor exemption from critical scrutiny. What it maintains is that its object — the divided subject, traversed by language and the unconscious — is not fully accessible through methods premised on standardization (Fulgencio, 2008; Roudinesco, 1999).

This is not a matter of opposing science to clinic, but of recognizing different regimes of intelligibility. Epistemological pluralism does not imply relativism. It entails acknowledging that human complexity requires multiple approaches, each with its limits and possibilities. Scientific maturity lies not in eliminating difference, but in recognizing it without simplistic hierarchization.

In the field of autism, this issue becomes particularly sensitive. If the goal of care is solely to enhance adaptive competencies, certain models may appear sufficient. But if care also aims to sustain subjective constitution and symbolic inscription, methodological exclusivity becomes restrictive.

The ethics of care demands more than efficiency; it demands responsibility toward singularity. No guideline can encompass the totality of human experience. No protocol can replace listening. No metric can exhaust the enigma of the subject.

The enduring question, therefore, is not whether psychoanalysis should or should not be recommended according to specific institutional criteria. The deeper question is this: what conception of the human do we choose to sustain when organizing our systems of care?

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Referências

Fulgencio, L. (2008). O método especulativo em Freud. EDUC.

Green, A. (1999). The work of the negative. Free Association Books.

Haute Autorité de Santé. (2026a). Trouble du spectre de l’autisme : Interventions et parcours de vie du nourrisson, de l’enfant et de l’adolescent. https://www.has-sante.fr/

Haute Autorité de Santé. (2026b). Autisme : Les nouvelles recommandations pour le nourrisson, l’enfant et l’adolescent (Communiqué). https://www.has-sante.fr

Haute Autorité de Santé, & ANESM. (2012). Autisme et autres troubles envahissants du développement : Interventions éducatives et thérapeutiques coordonnées chez l’enfant et l’adolescent. https://www.has-sante.fr

Klein, M. (1930). The importance of symbol-formation in the development of the ego. International Journal of Psycho-Analysis, 11, 24–39.

Korbivcher, C. F. (2010). Transformações autísticas: O referencial de Bion e os fenômenos autísticos. Imago.

Kuhn, T. S. (2013). A estrutura das revoluções científicas (12ª ed.). Perspectiva. (Trabalho original publicado em 1962)

Maleval, J.-C. (2017). O autista e a sua voz. Blucher.

Mélega, M. P. (2024). Pós-autismo: Uma narrativa psicanalítica com as supervisões de Donald Meltzer. Blucher.

Ogden, T. H. (1994). The analytic third. International Journal of Psychoanalysis, 75, 3–19.

Roudinesco, É. (1999). Por que a psicanálise? Zahar.

Tustin, F. (1992). Autistic states in children. Routledge.

Winnicott, D. W. (1982). O ambiente e os processos de maturação. Artmed.