From the Circular of 15 March 1960 the law of June 1990
From an organizational perspective, the "stirrings" of sectorization is in recognition of the place in every department of mental health clinics through the reform of financing of these structures implemented by the decree of 20 May 1955.
The clinic is both a place of prevention which facilitates access to care and hospitalization, and a welcoming place for patients after a hospital stay shortening it.
From a clinical perspective, it Sevres Group, created at the initiative of Dr. Daumezon , which was the crucible for the development of the sector policy before publication of the circular "historic" March 15, 1960.
The Sevres group worked two years: between 26 May 1957 and April 26, 1959. Six meetings in total, comprising between twenty and forty people, physicians and psychiatric hospitals, psychiatrists and psychoanalysts in private practice, monitors Ceméa, including Bonnafé, The Guillant, Jean Oury, and of course George Tosquelles Daumezon.
June 22, 1957, L. The Guillant from his experience of Villejuif, is a report on the prospects of a sector psychiatry that concludes: "The underlying purpose that inspired the organization of psychiatric assistance on the basis of a geographical area is indeed humane assistance. In this way converge knowledge of places and people, less impersonal relationships with various agencies and officials, consultations and services less impersonal with the various agencies and officials, consultations and services less anonymous, which will be for the people : their consultation, service, as Dr. so and so ... All this seems essential to find the humanity the doctor-patient, lost in this world of habit and ignorance, conflict and allocation of indifference and mingled, as they say, misunderstandings that characterize so deeply today, medico Social-where we work. It is obvious that to achieve this they must first be reduced to human scale. "
April 26, 1959, the group met last time around two themes with suggestions for action: •
for the sector: the Congress of Tours with a draft notice and interventions around Duchene's report;
• nurses for participation in psychotherapy, with ministerial bodies to amend the conditions of training and education.
The second point is around the guidelines set by the group of Sevres that will be developed an ambitious training of nurses, virtually completed in 1963, but which will emerge in 1973 as of a decree establishing the training requirements for nurses in the psychiatric sector.
The sector concept located in the continuity of that Institutional psychotherapy. It takes place in the evolution of psychiatry against the logic of the camps, the horror has jumped eyes startled the world, after the Liberation, sharpening awareness, I have highlighted, rejection and exclusion suffered by mentally ill people for centuries. Already at St. Alban's during the war, under the leadership of Tosquelles, caregivers travel the department of Lozere, however harsh winter that Tosquelles department called "the garden of the hospital" to go to the meeting of people suffering as close to their places of existence. The sector is a centripetal movement opposed to the design of centrifugal asylum.
In Paris, March 27, 1958, Philippe hinge founded the association of mental health and fight against alcoholism 13th arrondissement me. This is "changing the place of the meeting" with the patient, "a kind of prerequisite," said Hinge.
Psychotherapy and institutional sector are tools of alienation in the double articulation that it presents problems in the relationship of psychotic patients, ie when the psychic alienation, linked to disease, strengthens and crystallizes all the social alienation of identity, structural and organizational (status, hierarchy, etc. administrations.).
Hence the recovery position Hermann Simon in the dynamics of institutional psychotherapy on the importance of the atmosphere, surroundings in the dimension of care and willingness to care hospital in its hierarchical rigidities and statutory requirements that do not particularly agree with the clinical psychosis.
The evolution of the disease is not a given fixed once and for all by know science: "it depends" (Bonnafé) of the environment that accommodates the difficulties of the patient relationship. It depends on the attitude of others.
the environment is more fragmented, rigid, depending on the status of caregivers and non-knowledge links that are forged with the sufferer, the more secure environment will be less that an environment with "caregivers."
is why the industry relies on the intervention of a single team at the hospital and outreach sites in the city, to reflect singular links that develop between caregivers who are not exchangeable at the option of scheduling and sick people whose being-in-relation-with-others is rendered vulnerable by the disease and whose sense of continuous existence of one person to another, from one place to another, is extremely fragile.
It is important to understand that today, if this is a movement dealienating is not a movement of deinstitutionalization as some have, for some, wrongly stated (anti-psychiatry), and others confused , say maybe just ignorance.
Jean Ayme explains: "Unlike Anglo-Saxon use for which the institution is a hospital, from which comes the" institutionalization "to refer to the care of patients outside hospital, institution means in French, first to institute the action, then "everything that is invented by men in opposition to the facts of nature" (Littre). We refer more readily the hospital by the end of preparation and approach to the process and to treat patients in the tissue social "dealienating. "
This is not to raze the hospital to make the human care. What it is is to use different structures of full-time care, transform it, to "cure" them first, a mandatory aseptic said Jean Oury to open them in new ways shops for men. This allows clearance to humanize the methods of care on a daily basis and how to keep up with each other, both on the principle of continuity of care - including long-term, and the principle of equality and fairness between people (Professionals and cared) that the patients' speech is heard and that we take this into account.
The shape of the hospital, thanks to preventive interventions or early crisis situation, is no longer the exclusive form of psychiatric care that is well diversified across a continuum of reciprocal knowledge.
Deinstitutionalization in Italy, notably Franco Basaglia in Trieste, was reflected by the closure of psychiatric hospitals and threw many patients to wander the streets.
What is beyond in the movement of institutional psychotherapy and policy sector, so it's not the hospital, but its mode of operation asylum and hierarchical. What may be true for the army, becomes an absurdity with regard to care for people with mental health problems and particularly those affected by psychosis.
sector, it is not anti-psychiatry ( David Cooper, Deleuze, Guattari, Foucault ), this intellectual and political Anti-Oedipus or schizo-analysis , seeing the madness that the expression exclusive social alienation, denying the transcendental dimension of pathology aliénatoire regarded as a pure product of the contradictions and paradoxes of capitalist society.
The social alienation in Marx's sense is not to be confused with psychotic alienation. In other words, there is not enough to change society so that there are more fools. By cons, change the way of being with each other, change the look full of prejudices that arise on each other, respect the diversity of human situations, develop forms of mutual benevolence, share rather than exclude, marginalize change course in depth the lives of everyone and not just sick people.
Gaston Bachelard updates in aberrations scientists "in his deep desire to dominate men."
This discovery of the spirit of domination, in a text entitled "The formation of the scientific spirit," a spring is quite valuable for understanding how the hierarchical dominating positions that divide the human community, are obstacles creativity, to human inventiveness.
In that sense, yes psychotherapy institutional and sector policy have a subversive because they are the alienating nature of the psychiatric hospital, as a hierarchical system of caste status that places the patient at the bottom of the pyramid .
against this subversive, resistance will be many business applications in a surprisingly slow.
Jean Ayme believes that trying to "understand state and changing patterns of mental health 'forgetting' power, in the depths, domineering aspirations, with the secret powers of 'divide and rule', can only give knowledge aborted. "
As part of the work of Sèvres, the report that Duchêne present on July 59 at Congress Tours and inspires a few months before the circular of 15 March 1960 on the program organization and equipment of the departments in the fight against mental illness .
The circular of 15 March 1960 clearly outlines the organization to which must tend to more or less long-term organization French psychiatry.
This is to "split the department into a number of SECTORS geographical within each of which the same team will provide medical and social for all patients, men and women, continuity required between screening, treatment without hospitalization when possible, care with hospital and, finally, monitoring of aftercare. "
What is particularly important in this provision, it is the concepts of "same team" providing all the support, and "continuity of care "Screening to aftercare through the hospital stay.
The circular stresses "the need to appoint a team of medical and social burden of ill treatment in hospital and pre-and post-treatment."
She explains that it is "essential that the patient left the hospital to find psychiatric clinic, aftercare in the home, the doctor who treated him at the hospital."
She added: "The characteristic of the sector policy is that each team member or non-hospital has almost daily contact with others. "
In this text, the therapeutic and organizational meet on the following principles: •
separate the least possible ill of his family and his environment to avoid the mismatch induced by hospitalization.
• consider the transformation of psychiatric institutions and the "end" of the asylums were placed where people considered dangerous to society.
• open free services
• integrate psychiatric facility in a set of "outside hospital" providing screening, care outpatient and aftercare supervision.
• generalize the mix in services by ending the service reserved to a single sex.
The device consists of-hospital structures defined by the following circular:
• mental hygiene clinic and consultation in certain municipalities
• Day Hospital •
home aftercare (20 to 30 beds)
• sheltered workshops that can be created within the day hospital and aftercare homes.
organization generally based on a geo-demographic called SECTOR 67 000 inhabitants on the basis of the WHO standard of 3 beds per 1000 inhabitants.
However, a text written on behalf of the state is not separated from one dimension to satisfy both its own interests: any economic size and national management of costs are not excluded by the circular.
These provisions deserve it stops there because they are, in my view, already the seeds of future health policy and managerial acceleration at the end of the thirty glorious.
Thus the circular devotes a paragraph to what she calls "performance" of the property.
What's this? The answer is inserted in the text: "reduced length of stays and decreased the" sedimentation hospital.
If the goal is respectable, given the dilapidated sometimes sordid places of hospitalization in 1960, overcrowding, length of hospitalization unjustified, deplorable conditions of reception in some places, the term "performance" remains quite inappropriate in a document where concern for the care seems to be the first objective.
It foreshadows the economic recovery of the humanization of organizing the fight against mental illness by the massive reduction of beds and length of hospitalizations. This logic currently be pushed to the extreme with the ambulatory care without consent including the homes of people.
The illusion of a care that would cost less to the community emerges clearly: "the creation and operation of a day hospital are relatively inexpensive hotel purely because expenditures are reduced, in principle, only lunch and that permanence is not the nursing staff to provide day and night. "
drift is predictable, even some that is "organized" from the beginning of sectorization: operating strictly limited to 5 to 7 days, opening in time bounded 9h to 17h. Discontinuity of the host, availability, return to emergency situations, to forced hospitalization, etc..
Another term quite disturbing in the circular of 1960, that of "grid" used to refer to the organization of political area. The term "mesh" might have been better with regard to organization of care.
Finally something that is going to be the mainstay of the Mission Support Mental Health few decades after: on equipment to beds, the circular of 1960 already provides the ability to create attached to psychiatric wards of general hospitals.
And she immediately put on guard against the possibility that this drift is in it: "Do not forget that this organization will be able to treat all the mentally ill in the area that will serve not only a certain class of them, ie, the form of services of "acute" attached to the general hospital discharging their "chronic" on the hospital Psychiatric county is to be avoided. " Today
warning is undermined by the development of structures of medico-social field extension with the notion of mental handicap, which leads exactly to what seemed to avoid the circular: a so-called intensive psychiatric care of brief therapy, short-stay crisis and emergency subpoena medical and social homes by county Disability issuing guidance accommodation for people labeled "psychic with disabilities."
In review Rhizome No. 9 September 2002 , Jean Furtos editorial begins with these words: "Yes, the circular of 1960 was a revolutionary text for psychiatry sector, which yet has never experienced a golden age. "
Hospital, Fleury-les-Aubrais in the Loiret, year 1982, 22 years after March 1960, the hospital is almost the only modality of treatment in conditions of reception that I already mentioned above.
There are 5 areas of psychiatry adults and 2 areas of child and adolescent psychiatry, but little work "outside the hospital." Two structures within the circular exist and function: a mental hygiene clinic installed in downtown Orleans, intersectoral and home aftercare associative Navy Cross with boarding and therapeutic workshops, the Centre Maurice Parienté him also opened in the city.
Yet the movement of "alienation" has started well in the shade, the number of people hospitalized decreased and the movement will become even more acute despite the brakes on the administration.
administrative Why such resistance? By budgetary concerns. Do not forget that the hospital is funded, and therefore staff paid by the daily cost generated by hospitalization. Plus they are short, or down in terms of stays, less revenue is important: therefore more physicians are a policy area, the institution has a more shortfall to balance its expenditures.
I remember medical advisory board where the antagonism of views resulted in more debates than alive, even hostility between the protagonists to the objectives, management and care, diametrically opposed.
At the same time, teams that were installed in turn in some sedimentation in intra-hospital do not always actively involved in developing their presence in the sector, "out" as they said.
short, and it will take a combination of legislation, the 1985 legalization of the sector of finance reform, ending the tariff system the price of the day, replaced by block grant funding, and medical practices affirmed and pugnacious ( Roger Gentis, Horace Torrubia, Jean-Marc Chollet and their successors), including with nurses to help them overcome their obstacles, so that the circular of 15 March 1960 be concretely implemented.
Except that the glory years of economic and full employment, high growth are over. The 1980 which implements the sectorization are no longer in the same context as the 1960 Global: oil shocks have been there, unemployment has reappeared, public accounts are in deficit, the European harmonization of degrees nursing is running.
Working "outside the walls" is far from the only problem with restricting hospitalization: it is a challenge to established positions in a certain type of work he must accept to reconsider, including the psychiatrist: "so far," writes Horace Torrubia, where the psychiatrist assumes a sector, it does it is hardly possible to have a wait, and its activity can not be summarized to support the sick, in hospital or clinics, "on demand". The psychiatrist, assuming the sector, must assume all the problems within his competency, and truly integrate its activities in the social structure of its range. " That the desalination primarily concerns the doctors and nurses in their availability to others practicing in the area, and sometimes "no net" function psychotherapy.
Working "outside the walls" is working differently trilogy status, role, function, exit links of subordination asylum in which carers and cared for are taken. "Outside the walls," the question of the powers of one over the other arises differently. This is another act of the meeting is at stake than the places assigned caregivers-treated.
sector, it is not miraculous. More human perhaps, but if it does not work on the transfer, the transfer cons, if we do not have institutional analysis, hierarchical partitioning and verticality asylums and now are recovering and technocratic again invade human relations the speed of a galloping horse.
No device, no type of structure not be sufficient in itself to pretend to do without a collective work of permanent questioning preconceptions, prejudices, resistances, impulses of domination of one over the other, self proclamations etc..
Otherwise, in the words of Torrubia , "the mental cobweb" is formed again in the repetition of good conscience caregivers legitimated and sometimes reinforced by the "nobility" of work outside hospital .
Basically for the sick outside the walls, we must treat the area. It is always in d’asepsie Herman Simon qui voit juste et loin.
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