Humanity of care to test the law. Psychiatry hospital and laws to the test of time by Marie-Christine Hiebel Barat
You first say how pleased I feel to be with you to brainstorm, Friends Landerneau and in Angers. Thank you warmly for Madeleine Alapetite for inviting me to your work.
The title of the work day, Humanity of care to the test laws, is as fascinating and complex.
What reading do?
The clinical test of social alienation?
laws to the test at the clinic?
Psychiatry and politics?
Or the precariousness of human regulatory etc ...
The subject he questioned the possible coexistence of opposites that would care psychiatric and legal provisions that organize? As he interrogates a possible synthesis within the meaning given to the synthesis Francis Tosquelles ie moving to another level, a structural transformation? What would then the schema, the pivot point?
In psychiatry, the question of the humanity of care is fundamental. Psychiatric care, care for insanity is purely and simply the question of human existence in the report that the human being has with himself and with others in the relationship he has with the language that specifies as speaking beings , known to quote Lacan, in the report of his body with space and time. Axes of psychic construction, at the crossroads of the real, the symbolic and the imaginary, in their dialectical representation of things, representation of words and body image.
" Psychiatry hospital and laws to the test of time " is the first that you asked me to look more closely. In the test of time I translated "throughout history."
Madness has, throughout history, three features constants very important to me to consider in thinking that we are together today:
First constant
The "crazy" speech placed under the word "official" sign the report which maintains in the history of men's folly with the established order.
ERASME, Praise of Folly, XXXVI:
"The greatest kings taste so strong that more than one without them, can not sit down to dinner or take a step, or do without them for an hour. They prize fools than wise austere, they maintain the habit of ostentation ... buffoons, them, provide what the princes are looking everywhere and at all costs: fun, smile, laugh, fun. "
We are at the dawn of the sixteenth century in the West.
Madness, in the famous text of Erasmus in Amsterdam, is a prudent practice female figure endowed with speech codes stamped in use. This is reminiscent of another female character, that of Diotima, the stranger's wife Mantinea Plato depicts the side of Socrates in the Symposium.
The speech of Diotima carries, too, other than a speech to the speech agreed by the laws of the city. Socrates went so far as to recognize that only a woman in Greek society can make such "free" connection. Do we not hear from such "fools" about?
Subversion hovers above the floor as she carries the traits of authentic speech, which should not be admissible only because of the irrationality of the subject's speech recognition.
Madness witches will the heyday of the pyres of the Middle Ages and the Inquisition in all European countries. Joan of Arc and his voice, this young girl, courage and tenacity very strange, which drove the English out of France after having liberated Orleans, Rouen know this plight.
In the relationship that madness with political power, the organizational issues are closely linked to therapeutic
From the organizational side, the alternative may be stated thus: • the organizational
is designed as a translation, a formal motion, a practical implementation of the psychiatric clinic around specific of psychopathology and the unique history of each patient, or
• the organizational itself as a planning tool for land use model, standardize health (prevention and care) under societal demands and political context without considering the peculiarities of the disease and the singularity of the patient.
Echoing the side of the clinic, the alternative is as follows:
• Clinic deploys anthropological psychiatry (Jacques Schotte) ie takes the form of a human face psychiatry organized around the disease as a way to exist, ie a certain way of being in the world and the world. Then developed a therapy that takes into account the social dimension of individual existence, the inclusion of patients in the community, a psychiatry solidarity and openness on the city of men, because men are building the world with other men.
or
• Clinic folds into a scheme where the security is prevailing eradication Symptoms of the bulkier, less in line with the "conduct" socially labeled and segregated confinement failure (hospital) or repressive (prisons) and those whose behaviors are described as "abnormal" and "dangerous" and particularly with regard to people with psychotic disorders.
The problem with this close articulation of the therapeutic and organizational, that the dependence of care in relation to the organizational. Because when the second tacks and prevents the task of deploying in a shared dimension of humanization, psychiatry is so much suffering. Like today.
A conceptual design in my opinion can help us extricate ourselves from this dangerous liaison: the distinction between establishment and institution that insists Jean Oury to distinguish levels of what we are talking about.
laws, regulations, whatever the political stance of the legislature or regulatory authority, within the area of the development and clinical therapeutics, which institutionalized. What does this mean? That
logical state is expressed in laws and regulations is inherently different, or even reduced to the logic of care per se.
Sometimes the difference diminishes and convergences appear that enable easier humanity of care to people suffering, for example the circular of 1951, the circular of 1958 on the work of psychiatric patients, the circular of 15 March 1960, the 1985 Law on the sector. At other times, the gap is widening instead of making more difficult the exercise of psychiatry with a human face particularly among people with psychosis. And true he's now proposed legislation to reform psychiatry, prepared by the government office in this fall 2010.
The impossible synthesis and use of property-Institution distinction may be, basically, the only way to save a form of independence of the clinic through the process of institutionalization (Hélène Chaigneau) which is a shared process of humanization. This is the real work of patient care in the gap between need any work framed, framed in the regulations, and actual work, which always has the possibility to open a space for humanity.
is in this sense that I will remember instead the following wording: laws to the test of humanity psychiatric care: the ordeal of meeting (tuch) involves, tugkanon, one where after, it's like before the meeting that tames and blames the person who has tamed. When you know a person, we can not pretend that we do not know.
Only in this meeting here, humans are not interchangeable or as products of statistical units. What
Act today in the health economics restricted to the process of production and consumption, hospital-business and its goals of efficiency and performance of the activity could ensure such a quality human encounter? It is hardly possible.
This meeting belongs to the field of anthropological psychiatry, one that affirms Tosquelles that "without recognition of the value of human folly is the same man who disappears."
In this field, I am afraid that there is never any guarantee legislation within the meaning of the text prepared by men living in a time of power and responsibility to legislate on the organization of the city. The authority defends its interests first, it's human!
Field Legal anthropopsychiatrie is, for me, the scope of the universal, which is not the field general, the scope of declarations of human rights and citizen the field of children's rights in their universal ethical dimension as Immanuel Kant's categorical imperative in its formula. Perhaps I might say in the legal dimension "constitutional" sort of ethical framework republican controlled by the Constitutional Council which will decide the laws of the Republic. Would have to see if it holds ...
No law can legislate on the intake function, on sharing, on the collective.
But whatever the law, it is always possible to host, share, create a community caregiver, if the desire is there. This did nothing illegal. It's more or less easy according political conditions. This is not always the law that prevents that effect is created when a club is experienced daily therapeutic way to be with each other different vertical hierarchical system. But if this is not the law, then who is it? Here we are in trouble to meet ...
we know, the most spectacular in terms of humane psychiatric care occurred in historical times remarkable in the struggle to conquer and defend the freedom of men after the French Revolution Pinel, Freud and psychoanalysis between the two world wars, the movement of institutional psychotherapy at the Liberation and the horror of the discovery of the camps extermination and concentration Nazis and policy area in its wake in the 1960s.
The State and the laws it establishes, are necessarily, I mean "necessarily" with something about "that's" more or less accentuated, in a logic intervention, control, control in a denial or ignorance of the "unconscious": the law is expressed in terms of life plans, statistics, evaluation. Even the most fetishized circular 1960 on sector policy uses the word "return" of institutions and the word "grid" of the city by the sectors.
time this law is cyclical in the short term, a term lasts five years. The time of psychiatric care is an entirely different nature: the time of timing, which can not be decreed, the kairos.
Another example: the humanization of hospitals and interventionism in the daily life of psychiatric inpatients: is it the law, if favorable to the rights of patients as it is, to regulate the mix or not, the law to have knives or not to smoke or not etc ... because the law authorizes always carries with it the possibility of its opposite. The smoking ban is a good example.
These provisions are obviously strengthened in a logical security state that we know today. This logic is indeed based on principles that separate the organization of care of the humanity of those to whom they are addressed: the human animal has the difference was not a territory but a private space of existence that s articulates with the public and social spaces of the city.
Law Hospital, Patients, Health, Territory: HPST.
The territory is given where the logic of biopolitical spaces confusion occurs.
The notion of consent without any psychiatric care home is in my view paradigm: Abolition of private space, at the request of families themselves in great difficulties, and seduced by all that present themselves as solutions to them without analysis of what the facility in terms of deprivation of liberty can lead to all of us.
"On behalf of the law, I meet you at your place of residence to arrest care. "
How in these conditions for patients living in the city without segregation and stigmatization? How
for professional care in such an intrusion of private space?
Not easy, perhaps!
's home, place of residence is a home or personal space in which the public does not have to break a space to meet both out of a sense of confusion, help differentiation, separation without undue risk of collapse existential case of persons suffering from psychosis, but also for does not exacerbate disease paranoid anxieties of conspiracy, threats posed by the environment sometimes for some patients who interpret to birdsong and for which all beckoned.
For staff who will be subject to this requirement, do not they see their work move from a public service approach to the implementation of a logic state, a practice of meeting health care, and mutually agreed knowledge, a unilateral intervention safe?
Families do not they likely to realize too late disastrous consequences of what they have both claimed?
Philippe hinge, about home care practices, writes:
"Home care, even if made by a team of industry, always at risk of being perceived by the patient and by his entourage as an irruption, a penetration abuse in her private world. "
He continues: "What concerns us is the danger of replacing the potential therapeutic application of patient care by the desire of the team (...) When we press the doorbell of the apartment, we ask applicants to" .
He continues: "What concerns us is the danger of replacing the potential therapeutic application of patient care by the desire of the team (...) When we press the doorbell of the apartment, we ask applicants to" .
regard to desire, should we not be alarmed to see in the future bill that treatment without consent can be implemented without application of any kind, on a simple medical decision outside the institution? True, it is often difficult to obtain an application, including emergency, but is this not a necessary guarantee against arbitrary, any precipitation. The logics are often simplistic and simplifying liberties. On behalf of access to care, lurk intentions of a new order, dangerous to democracy.
The highest walls of the asylum are the ones we build in our minds and that is commonly referred to as bias. Should be able to expect the law at least not to mix prejudice and expectation of the people, even families.
Why can it be otherwise?
the answer lies in the second element that seems to me essential to emphasize in order to better understand the complexity of what is played through the organization of psychiatry for the man in humanity that specifies:
organizing support the madness dealing more than any other medical discipline with the xeno / phobia is the fear of the Other within us.
The song is well known:
Something like:
"If the other man does not exist, whether men hear less human than others do not exist , sub-human example, so who am I? On which to base consideration, esteem I need you for myself? And how much of these men, I feel different from me and called crazy, I carry with me? What's going on there for me, if like me, for be who I am? "
Here we touch upon the individual and collective imagination, the representation of madness and mad over the image we all have of ourselves and that we want to preserve and protect any price. I'm not mad, I'm not crazy, crazy what are the others I do not want to know anything for fear they teach me something about myself, my conscience, and of course deep down I already know!
And the law and regulations resulted in legal terms this imaginary society. From
so, again, more or less pronounced.
The prejudices of man over man are tough because they affect the very basis of human existence: the mad, the other, which I think is radically alien to what I am up 'to look abroad to the human condition that I pride myself, until reduced to a "case" which the company is afraid (events) and against which it requires political organization of psychiatry to be protected .
Act of 1838, for example part of the movement from humanist ideas of the Enlightenment and the French Revolution. The declaration of human rights and citizen has been there and it is very useful to recall today, while preparing a new law on psychiatry that places the issues of emergency preparedness in the forefront of system of care for psychiatric illnesses.
Act of 1838 perfectly illustrates the paradoxes that I just mentioned: it is a security law (involuntary) that affects individual freedoms, but also a law that establishes for the first both sites treatment of mental illness from which the medicine will gain legitimacy in the field of insanity which thus enters into the medical field and therefore care.
The threat of madness that hangs over the company of "Normopathy" is very important to consider and render inoperative, to dismantle the organization in terms of living with each other. Because that is precisely what is at issue when discussing the organization of psychiatry live with each other. This is not a philosophical position or abstract ethics. This has direct consequences and immediate impact on daily life of a very large number of individuals that should be considered.
In this vein, the report gives Couty "mentally ill" defined-accurate representation and fully encompassing, in a general formulation of a peremptory supposed to know that sticks with the representation of social knowledge held by the position of authority he holds:
" In many cases, the mentally ill have for a long period, awareness of their illness.
They perceive their pain but can not express it in a streamlined supply of accessible, financially and geographically. In contrast to people with other diseases, they can also simply express a need for diagnosis, care, and support. Consequently, expect the demand for care by the patient himself, can only delay the diagnosis and implementation of a customized treatment plan.
This time has the effect of placing the person himself, his family and relatives, but also professionals in situations that can be serious consequences .
About These incantations are alarming, really.
should explain to Mr. Couty men build the world with other men in a process of humanization shared respecting the infinite complexity of the human person. The security approach of madness is the opposite of a world open to the presence of others that welcomes all people with their differences with what distinguishes them, with their singular being. Instead of apprehensions, fears, prejudices, this world of shared humane, that sometimes found around the corner, this happens fortunately given way to the distinctive, large and small differences, the fragile lives, sometimes precarious, with mental health problems in relationship difficulties.
It should also be noted that Mr. Couty presence is not in the moment, it is built in co-aware of each other. It is the spirit of the policy area: long-term presence, long-term acute care.
Fear is the engine of safe states. More police is a state, its rulers stoke more fear of imaginary people towards each other instead of taking real steps to appease him. How? With scapegoats. Really, this is not new.
The myth of dangerous madman is stirred properly and conscientiously pursued objectives. That fear, which gives a menacing form of madness, according to patterns of representation in accordance with social codes ancestors. What is a mode of existence among others becomes a threat to ignore. This different way to exist is then framed strictly according to regulations and arbitrary decisions. Prohibitions, submission, obedience, sanctions dominate the social order.
Embracing diversity in its cultural, social but existential, is trying to build a heterogeneous world, rich pastry, which is composed, without any absurd notion of classifying individuals by statistical series of symptoms: depressives, alcoholics, schizophrenics, etc.., that list can be extended to envy foreigners, the handicapped, the undocumented, the homeless and many other categories, the Roma and Travellers in summer 2010, when the singularity is dissolved in the bulk of the group to which people are assigned.
The man suffers from its human situation. In this sense that Freud sees human neurosis privilege. The question of the meaning of life nourished since the dawn of time, melancholy under the auspices of Saturn. Neuroscience as powerful as they are not coming to solve the riddle of the human condition, speaking beings that we are to use this expression of Lacan who goes to school.
speech on the organization of psychiatry involves keeping in mind the paradoxes and contradictions raised rapidly above and include:
• the devices modeled the homogeneous state structures, not consistent with the singularity of existence. The therapeutic encounter is only possible in the relationship of the therapist vocabulary (recent) to a singular person, the organizational system does not reduce to a collective identity which has lost its identity.
• the first step towards integration is often the first step towards the care and the insertion begins from the hospital stay, provided that it is something else a systematic development in pajamas or put in an isolation room directly upon admission.
Henri EY
"Mental Illness as links as alterations of coexistence with others, depends in its symptoms and its evolution, the attitude of others."
We heard the AMPI Days 2010 a great response team Marseille telling attendance throughout the course of a young teenager, became in time a young adult, respectful of his work transference constellation, including a person that meant a lot to her, which with time passing for it too had changed its service and has agreed to return to meet regularly once a month. Yet nobody has pointed out, during the discussion, that this young woman had been in an isolation room and the evening she was tied with restraints, and she cried while the nurse who wept as the 'attached. What we all pushed to do anything to regain what had been said, however, we clearly?
• that psychiatric illnesses are diseases existential seeking long-term acute care throughout life as many other physical illnesses (diabetes, vascular, cardiac, renal).
"When social alienation is too demanding, they (psychotic patients) risk their lives. They are indeed confronted with a chronic banal human existence, but threatened by the "sedimentation", which puts them at risk of "falling out of the world." This exclusion alters, unwittingly, the humanization of the "healthy" forgetful who think themselves enrolled in a life worth living. In psychiatry, prevention is not reduced to a morality which, knowingly, everyone should abide by to avoid falling ill. But it is the result of an ethic which is acute care collectively to implement those whose balance has been upset by the emergence of the disease, "Dr. Michel Lecarpentier.
it finally exists to use expressions of Lucien Israel, professor at the University of Strasbourg, the "dungeons diagnoses" and "structural ghettos."
Horace Torrubia psychiatrist original English, I had the chance to meet early in my administrative work at the psychiatric hospital in the Aubrais Fleury, nicely expressed in his book "The institutional psychotherapy in heavy weather." He warns not to pay all persons who are experiencing psychological distress and acting out some criminals, it is true, in some patients.
DELION Pierre, Professor of Child Psychiatry University Hospital of Lille, psychoanalyst
"It is important to remember that any mental illness, psychopathology, is carried and lived by a person. A psychosis in itself does not exist ".
This globalization, this generalization of suspicion of the potential threat to other patients is inconsistent, he said, with the "presumption of innocence applies to everyone and individual freedoms that accompany it, the presumption of innocence is being undermined unfortunately also in other fields as psychiatry.
Torrubia Horace wrote: "However, this principle (presumption of innocence) is strictly reversed with regard to the mentally ill, meaning that by mere confinement the patient is in practice considered the facts as dangerous and irresponsible until he proved otherwise. Upon entry, the patient is tainted with suspicion on the part of society. "This sentence is
extracted from an article dated 1959. It could have been written today half a century later. This is not new. But it continues to repeat itself. Meanwhile, stigma persists and is reinforced as at present. The resistance to changing humanist, a different conception of man, the evolution of ethics is enormous prejudices. Inertia fantastic.
extracted from an article dated 1959. It could have been written today half a century later. This is not new. But it continues to repeat itself. Meanwhile, stigma persists and is reinforced as at present. The resistance to changing humanist, a different conception of man, the evolution of ethics is enormous prejudices. Inertia fantastic.
During WWII, persons with psychiatric disorders and staying in care facilities during this terrible period are mostly depleted.
This tragic period just highlight a third fundamental constant when you think the organization of psychiatry
the question of the value of human lives .
In Germany, the Nazi ideology of a healthy person takes a form of systematic eradication towards the sick and disabled and condemned to extermination by euthanasia. On this unspeakable tragedy, books were written, and films, I think the film Amen by Costa Gavras. The figures show that about 50% of chronic patients, 70 000 people were murdered in Nazi Germany by the gas and that 20 to 30 000 have been abandoned to their fate without assistance to die.
In France, the slaughter of Fools is estimated at 40,000 people died of starvation, neglect, cold in asylums.
ideology of man "biologically superior" to hear a healthy man, enacts some lives unnecessary and costly for the economy of the national community. Victor von Weizsäcker, neurologist and philosopher, states clearly: "The excitement of life as a pure biological product demonstration ideal conditions for the elimination of lives that represent a lower biological value."
two Nobel laureates French, Alexis Carrel and Charles Richet, have publicly urged the removal of "tainted" and "useless." Do not believe
naively that those days are forever behind us: the price of health, and therefore its negative form the disease is one of the current challenges of globalization and the economy of France in particular through the accelerated transfer of care and support for health to the medico-social, and financial viability of public hospitals with pricing in the act and the concept of hospital-company I already mentioned.
course, this is not eugenic policies. But today there is a real revival of creationist theories and degeneration through genetic research aimed at finding scientist in a way the causes of some psychiatric disorders. Scientific advances on cloning, artificial reproduction, breeding techniques of physical characteristics or gender of unborn children have a real risk of eliminating human labeled "imperfect" that would not have the right to be born.
Chemical castration of rapists criminals is also a real resurgence of ideologies of the perfect order and the rule of the superior man.
In his book The extermination of the mentally ill in Germany Alice Ricciardi von Platen Nazi quotes the Prince Philip von Hessen who tried to assert his opposition to euthanasia: "Despite my ardent recriminations, he was told that I should resolve to act with the necessary firmness and that I had to understand the general situation of the economy that did not support in time of war the sick without hope. "
Patients without hope, the terminally ill do not report anything in terms of productivity in the economy but to play only in terms of spending on the fiscal balance of a nation. In Clearly, they cost more than they relate. Their existence is it worth the price it costs the community? Alain Minc has placed recently on this subject on the elderly.
But there is no darkness without light. During the years when the troubled World War II, hospitals will also be places of welcome and protection for those who are ruthlessly hunted down and hounded by the Nazi occupiers zealously helped by the Vichy government.
is also the beginning of the extraordinary human adventure and Clinical Hospital of St. Alban, in Lozere at the instigation of Francis Tosquelles, the hospital committee, the club therapy, a story you know well.
the Liberation, minds are reeling from the discovery of the concentration camps and extermination. Physicians and caregivers deportees survived the tragedy, show the horror of concentration camps and desolation of the world of human relationships that they have faced.
All the psychiatric service was detained and questioned by the logic of the camps and concentrations of people deported. The eyes and minds open to the terrible consequences of confinement, the shunned, the stigma of the depersonalization, lack of dignity and, more generally, the deprivation of basic human rights .
The circular of 15 March 1960 will give legal form to follow the movement of institutional psychotherapy with recognition of the sector policy, sector legalized by the 1985 Act and that the law applied to psychiatry HPST challenges Because the benefit of the logic of territory and that the report calls Couty " sector renovated .
This logic is running from North to South of France, we have heard in its concrete achievements to Lille National Days Navy Cross, as the Days of AMPI in Marseille where day-care facilities were grouped with unrelated geographical area served. They are even in the workshop I attended, professional medical and social field who testified or warned about the suffering of people they "accompany" a result of these reorganizations hospital system.
"They perceive their pain but can not express it in a streamlined supply of accessible, financially and geographically "look more closely at the context of provision of ultra-liberal society which refers to the point of view Mr. Couty:
competitive institutions and hospital services, controlled decrease of average lengths of stay, reductions beds, staff resources, fetishization statutes, control of landslides tasks, daily fee charged to patients, outputs precarious partitioning care facilities intra / extra, grouping patients by homogeneous conditions, confinement, solitary confinement, restraints, educational and therapeutic protocols, assessments on any axis.
Cruelty policy? Willingness to dehumanize the context of care where personal history is a source of wasted time and therefore money to borrow a popular shortcut?
laws to the test of the humanization of care. There are times when undoubtedly alter the framework to make treatment more complex than others. Certainly we are in that time. Hopefully this can change rapidly in order to facilitate the emergence of collective caregivers source of creation, association, freedom.
Madness is in constant dialectic with the freedom of human beings. Not surprisingly, this is the precise point of the deprivation of liberties that the law intervenes.
