source: http://www.cedep- europe.eu/sem/sem05fra/Cano.pdf
Ethical foundations of institutional psychotherapy
Introduction
Dr. Nicole Cano
institutional psychotherapy is a model of theoretical development and practice of using psychiatric care so ordered for psychotherapeutic place for exchanges and meetings which is welcomed and treated the patient.
This movement was born in French psychiatric hospitals at the end of World War II, in a political context and sociocultural concerned with human dignity and democracy.
Its principles are derived from one hand, recognition of the pathogenic effect of asylum known psychiatric hospital in 1937 - which led to the crash of the existence of the patient - and on the other hand, recognition of the uniqueness of the individual and subjectivity suffering psychic.
Therefore, institutional psychotherapy articulates two dimensions: sociological and psychoanalytic. It advocates use of the institution in its aspect aimed at establishing a system of symbolic mediations fostering a dynamic exchange.
It induces creativity in the hospital world it has turned, causing the current organization of public sector psychiatry: inside a geodemographic territory, the same team responsible for all patients continuity care using varied structure - With or without the possibility of hosting - and performs work in the direction of the population.
gradually since the 1980s, there has been a challenge to its foundations, along with the rise of neuroscience, the extension of the sphere of law, with budget cuts and new requests to the psychiatry the social and political field.
This context facilitates the emergence of statistical methods and goals of understanding of mental illness, definition of it and the patient, leading to the emergence of practices wanting to be more rational for the sake of efficiency.
There is talk of crisis in psychiatry. The term seems appropriate because this is a disruption of the theoretical and clinical factors associated with previous external and internal environment. Like any crisis, it has several potential solutions: a pseudo-equilibrium leaving dysfunction worsen insidiously with reinforcement of defense mechanisms, a solution where catastrophic psychiatry no longer meet its mission of care or a positive solution incorporating contradictions and leading to an equilibrium level. This reflection
on the movement of institutional psychotherapy is not nostalgia for a bygone era but a sense of concern about new forms of care offered to patients suffering from mental illness.
The idea is to submit an ethical questioning this therapeutic model to see if it conforms to the fundamental concepts of ethics, if they can enrich it and if it is legitimate to pursue this direction.
Psychiatrist Hospital. Hôpital de la Timone. F-13 Marseille
I will then current views and perspectives of psychiatry in light of everyday clinical experience and reasoning of medical ethics which I hope they will guide the psychiatric action if the choice is still possible.
I-A few words about institutional psychotherapy
1. Historically
It should be noted that the outrage is the finding of the involvement of medicine in the process of dehumanization at work so hard in the Nazi barbarism, and softer in psychiatric hospitals, which led to the birth of medical ethics modern and institutional psychotherapy.
While medical ethics advocated the principle of the primacy of the human person on science and society, psychiatry placed the patient at the center of the aims of care.
2. The major concepts are
This institutionalization, transfer and cons-institutional transfer, transversality and institutional analysis.
Through the process of institutionalization , caregivers and administrative - the management function is to ensure conditions of care - transform the institution institutional treatment, by enacting a local law which is the obligation to share. This process acts as a third term mediator. It is about creating different meeting places, mainly the activities, but also the meetings and all the moments of everyday life (food, drug delivery ...) which are an ideal opportunity for the outbreak of trade under the next to the third office. This comes as the law allows a father's desire that something is built and dialectizes with each other.
The objective is to enable the patient, through the activities shared with others, and linked to other sites set up to participate in the institutional frame that is the set of individuals and contracts and rules governing their trade. The patient can then locate or relocate in a symbolic dimension. If
institutional psychotherapy can detect, to better treat the psychotic process, it creates a symbolic support useful in the treatment of other psychopathological processes.
It is in the foreground the individual with a unique history and argues that the disease can not be grasped objectively as such. It is inseparable from the feeling to exist and how the patient expresses it and to whom he expresses. It is within the therapeutic relationship, the transfer , that suffering and symptoms make sense. In
institutional situation, the transfer does not go to a therapist alone but to all caregivers, organizing social system (decision authority) and even hardware of the institution (physical environment, architecture , configuration spaces, provision of premises).
analysis cons-transfer therefore not limited not the therapist's unconscious reaction and the terms of the dual meets, but the analysis of the institution as a whole: the emotional reactions of caregivers involved, their interrelationships, and the hospital structure itself, because All these factors mean that every patient's place and status.
We know the influence of institutional structure on the type of symptoms, their appearance and disappearance, and the nosology.
We know for example: o it is sufficient that two therapists responsible for the same patient differ in their secret how to see and handle his case or that the patient is agitated delirium, o respond to an authoritarian and regressive symptoms than contrary to tolerance and let them meet the extremely aggressive acts and self-destructive o that ambiguous situations inviting space while the impeding movement (during closed gate, doors closed) cause or exacerbate stereotypies.
The care of the environment is an integral part of patient treatment. It requires constant vigilance on the degree of cross a dimension that is constantly challenged and that tends to happen when a maximum communication occurs between all levels and especially the different senses. It is contrary to the modes of transmission of a pyramidal hierarchy which sterilizes posts, paralyzes the floor and causes a depletion of the initiative.
If the coefficient of transversality is high, the team is a group-subject, has a hold on his conduct, and only then can a dialogue be established between the group and the patient who may be himself.
is essentially team meeting that is institutional analysis will .
Beyond the facilitation of information, the overall goal is to understand the patient and the community articulated itself, with the company.
In meeting that may be linked, articulated all dimensions of life of the patient and the various opportunities to be perceived differently by those around him. These aspects are brought together and it follows from developed on the conscious level, throughout the team, as the relations of the patient.
Analysis the cons-institutional transfer also requires the analysis of relations between all members of the team. Indeed, conflicts, discrepancies are troublesome if not denied. If they are, they will express themselves through actions or non-actions, words and silences that will affect the patient. The principle is to highlight the obstacles to the functioning of nursing, to show the meaning and benefit from it.
Institutional analysis will also detect if the institution complies with its official function - care - for other functions not recognized act symbolically on the patient, we can not relate to the therapeutic function (security function, business function care ...). This system is defined more broadly over the entire socioeconomic system. This will adapt the organization of the sector and the hospital so that the patient is at the center of care project and discuss with other bodies involved in organizational politics of psychiatric care.
3. The psychiatric sector
dealienating This movement and anti-segregation promoted the sector psychiatry whose principle is "to separate the least possible ill of his family and his environment "(Circular of 15 March 1960). The bursting of the hospital in small units scattered throughout the community does not remove the institutions and the issues they raise. This is an extension of support to all sociological sector, enriching moments of preparation for the patient and the team, provided there is an articulation of the various structures involved in patient care.
This device allows the addition to the same patient to enroll in its path in places offering varying degrees of mental capacity and thereby facilitate the analysis of transfer on the frame and work the issue of dependency. In
Indeed, the group treatments are only a means and not an end in itself, and institutional psychotherapy good conduct can lead to individual therapy.
also a growing number of people with diverse pathologies speaks directly to community mental health center for outpatient care.
II-Ethical reflection on the institutional psychotherapy
It focuses on the legitimacy of the principles that underlie this practice.
Different typologies classify the organizing concepts of medical ethics. We borrow one referred to by P. Lecoz, philosopher at the Espace Ethique Méditerranéen de Marseille.
The demand for justice founded the practice of medicine. It is expressed through three fundamental principles: autonomy, beneficence, nonmaleficence, that rules in the daily update.
1. The imperative of justice
Justice is, according to Socrates, an idea, principle of our actions shaping "a global way of relating to the whole being .
The right attitude of caregivers vis-à-vis the patient is not to fix his difference in the peculiarity of his situation, but to be recognized as aspiring to feel at home in the world. Hospitality requires him serve his membership in the human community.
Psychotherapy institutional response to the imperative of justice insofar as it is built around principles that relate to the patient as a whole, which is different from a summation of points of biological, psychological and social. It considers the disease as an experience of a about singular and unique, made in its culture and history.
She believes every patient as his similar despite their differences, whether related to its mode of admission (free, or without consent), its diagnostic category or social.
It takes account of these differences through the individualized treatment plan: it is institutionally meant the patient is expected of him for a collaborator, he incurs a share of responsibility. It finally acknowledges the desire of everyone to introduce meaning in his life.
2. Ethical principles Fundamental
These three principles should guide the practice together, but depending on the situation, one of them becomes predominant, but exclude the other two, which can then exist in the type of lens care.
The principle of autonomy is still on the horizon of the psychiatric care that seeks to limit the scope of determinism and get free from the subject.
Although autonomy is limited in its Kantian (the ability to have its own laws), it must remain as described. This is to reinstall the subject in its position as his life, capable of initiative.
For this, he needs benchmarks: place humanly habitable with spatial-temporal framework and constant differential (planning activities, group meetings ...), referents caregivers.
It also needs to refer to himself in the mode of an agent capable of introducing changes to the outside world and in his own body, setting in motion the powers of his mind (by the activities ergo -social therapy, sports and cultural), restore a sense of community (through meetings, activities ...).
To this end, caregivers must be real cooperation, participating in a common task, but the group must allow for individualization of each member so that a personal word may arise. This is a condition that everyone can take responsibility for others without hiding behind collective responsibility tends to remain anonymous.
Ethics acts as a space of reappropriation of meaning through a deconstruction of the representation of nursing as a performer, which alone can enter the patient's emotional and intellectual dynamics. This requires a questioning of the emotions and the rules governing the discussions. The imperative of justice requires an exploration of the reasons that lead us to experience a particular emotional experience and consultation following the rules of discourse ethics of Habermas specified by the absence of hierarchy related to the statute, the only pole transcendent being that the best argument .
Institutional analysis thus responds to technical reasons but also strictly ethical.
The principle of beneficence dictates to perform for the benefit of a patient that he can recognize, which is difficult to assess in the context of psychiatric care. One can nevertheless assume that the patient waits caregivers: a home of his suffering and facilitating the resumption of life.
To this end, caregivers must make use of a theory based and above all a sense of responsible clinical practice, focusing on the patient's speech, taking care not to substitute their own values with those of the latter.
The principle of non maleficence guide our approach by looking not to interfere in the individual experience of suffering and does not require the patient which perpetuate or exacerbate the start of its capacity of independent thought.
Thus, the movement of institutional psychotherapy and psychiatry sector meets the criteria of ethical validity, which justifies that they meet the conditions for its continuation.
decline is it related to a loss of its primary essence is that it existed nowhere but to be always under construction?
Some were they left contaminated by the certainty of having the right theory and practice once and for all, contributing to the abandonment of the institutional work itself and to identify the area of inert structures and fixed ?
This decline is not also an indication of a definition different from humans and disease in society?
III-The current guidelines for the care
News and future prospects indicate that the new designs is needed psychiatric care and gradually.
1. neuroscience and medical-technical orientation
Advances in biological therapies have contributed to the achievement of institutional psychotherapy. Their effect on the symptoms and suffering of patients and the environment has facilitated the management relationships.
In what way the growth neuroscience threaten it this movement?
knowledge of brain mechanisms is progressing, but that we can currently hold and simple mechanisms to form a comprehensive theory of human neurochemical, mental illness and psychiatry. In genetics, recent studies suggest the malleability of gene expression and influence of cultural processes. Advances in neuroscience, since the early 1980s, did nothing to contradict that fundamental clinical research has helped develop.
This is not the scientific knowledge that is involved but the relationship to knowledge. The desire for access to the knowledge of truth, which requires the theoretical and conceptual language is not in itself a factor of impaired relationships with others and participate even indirectly, to ethics. But the report knowledge can familiarize individuals relate to their peers so objectifying. The report to the next is dictated by an alleged truth that sits between the patient and therapist, preventing a true encounter. This reductionism transforms theory into ideology, suturing the relationship to another.
These are not the neurosciences problematic but their recovery as pseudo-scientific cause and purpose of psychiatric care. This position
linear causality is relayed by pharmaceutical companies to support their argument. Thus the tendency
simplifying room, grabbed the assumptions of neuroscience research leads to reduce mental illness symptoms target, to abandon the conventional psychiatric nosology and psychopathology references to descriptive classifications of mental disorders, eliminating the subjective dimension of suffering, which is proven an intimate without possibility of verification by direct observation and measurement.
This orientation may lead patients to be distributed in specific structures based syndromes (onset of schizophrenia, anxiety, depression, agitation) that we may see crystallize at the mercy of events cons-transference.
Symptoms and torn from the unique structure of personality are then coded and statistically apprehended which will classify patients, evaluate and streamline (more effective and less costly production process), regardless a psychotherapeutic model that assumes an efficiency based on the therapeutic relationship.
The prevalence of codification and measurement on the human relationship and therapeutic invades the space of care. Time is held to be quantifiable and it is no longer the cutting time and space for events produced in a structure that gives meaning to thought and action. Work is under protocolisation project called institutional imposed as part of a technocratic hospital without questioning on mental illness and responses to it, and hampering the initiative and creativity of teams. Hierarchies are formed and solidified, management techniques appear.
What is the overall treatment plan of a team pluricatégorielle, research of a high level of transversality and institutional analysis? This design carefully confiscates the responsibility of caregivers, a necessary condition to the vision of patient empowerment.
Membership caregivers in this classification system is outside does not have a pathological anxiety about the disease and the dislocation current foundations of psychiatry? The inability to find refuge in a theory that underpins their practice gets them does not adopt the tools presented as scientific and neutral to better neutralize their anxiety?
Neo-language scales, grids, targets, conduct, transparency, measurement of quality change their thinking process and participates in the objectification of the patient and compartmentalization of care.
Ultimately, the risk of medico-technical orientation that is part of an accounting and financial logic is that of patient selection for productivity Max. The allocation of resources takes account of the activity - with reservations about the appropriateness of the means of measurement - is one thing, there is unequal treatment of persons facing is another, which does not appear consistent with the imperative of justice.
2. The civic dimension and mental health
recognition of the citizenship dimension of the patient is necessary.
Psychiatry citizen helps locate otherwise psychiatry in the minds of everyone, the goal is to deinstitutionalization and includes a work commitment and accountability of the political and social development.
is the reduction of the patient that his citizenship is problematic because, in any case, the social response can be in itself a response to the fact psychiatry. It is emerging from the delirium of myth that the psychotic or neurotic access to the social. Psychiatry can not deny the sociological approach to the middle without alienating his own practice, but it can put the social front without the risk of being lost.
Hoping to stand out in a biomedical psychiatry does not consider the subject, psychiatry citizen might finally make it as a suspension of about as a thinking being and wanting, and exempt caregivers to consider the symbolic and imaginary effects of their words, their deeds and institutions.
recovery of the notion of citizenship by technicization and ideological currents running through contemporary culture leads to the transformation of psychiatry in mental health.
The use of this concept by psychiatrists, in its origin was to alleviate vis-à-vis the population, the connotation of the term considered too heavy Psychiatry. He has been revisited and interpreted as dilution of madness in the office. Therefore, the field Mental health is unlimited. Appear simultaneously new signifiers - user, stress, scourge, network - which does not rely on the clinic and the specific character of psychopathology but are a means to promote new lines.
The danger is to objectify a symptom medico-social or psycho-social process uniquely within the supported mass of the target populations.
Psychiatry is thus challenged in responding to health scourges - like AIDS - to situations of natural disasters or not, situations of precariousness, exclusion, violence.
This request for hearing by the social psychiatry as a society of mass is correlated with the erosion of social ties and the weakening of institutions. Less
institutions produce mutual exchange founder of the identity of each, plus psychiatry is convened at the same time as charitable organizations.
psychiatry is no longer a purveyor of meaning but of human relations and tranquilizers.
But the act is not psychiatric in the order of the good deed. It requires a theory that defines a framework and only if the suffering individual development that defies the use of mental care arises. Otherwise, psychiatric intervention is only a matter of exclusive relevance of the principle of beneficence - revealed by the emotion of compassion - to the exclusion of the principle of autonomy - revealed by the emotion of facing a compliance Estimated person able to overcome its vulnerability.
Is this not also calm the complaints and even anger of individuals suffering from damage stemming from society? This would entrench
then psychiatry in terms of regulation social.
3. orientation safe
The daily practice reflects a change in thinking and behavior of caregivers vis-à-vis patients hospitalized without their consent.
The desire to respect the procedures, along with the rise of litigiousness, replaces the ethical questions of the legitimacy of a refusal of care.
The legal constraint, which has a symbolic value, turns on a more systematic and by protocols in physical restraint with the proliferation of closed units, the current use of isolation rooms appariton and equipment restraints. This control is done in the real detriment of the mental capacity and the development of demand for care.
But the purpose of the hospitalization is to allow the patient a constraint that can not be imposed on itself. The institution, in its dynamic aspect, acts as a self-limiting factor that allows the release and renunciation of passion. Freedom ceases to be an inner feeling, it is the result of conquest, overcoming the constraint. For this, the law must be fair institutionalized, that is to say that she spends the aspiration of individuals to self-esteem and increased sense of identity. If the constraint is absurd and violent, the institution is more legitimate and individuals are left to the agitation of their desires.
IV Need for refocusing ethics
It appears that the movement of institutional psychotherapy is distinguished not only by the relevance of its concepts - the question of the theory can not be reduced to the choice of true - but especially its ethical namely the major interest in the subject and condition human.
psychiatry struggles to find within their own discipline sufficient resources to operate an ethical conversion, as happened after the Second World War.
She finds no support in a political environment and socio-cultural individualistic, driven by pragmatism, productivity and value optimization of well-being.
It seems that to continue along the path of ethics, she has to seek redress from other professionals interested in human beings: Philosophers, psychoanalysts, sociologists, anthropologists, neurobiologists ...
reflection could be developed within an independent ethical space, with institutional legitimacy, for an articulation Psychiatry - ethics at two levels: a theoretical and clinical and theoretical and political level.
At the clinical level, the ethical approach is grounded in the sensory experience of the intersubjective relationship and requires us to reflect on the elements (emotions, context) that determined action: what was the context? what were the emotions? the principles revealed by them were they adapted context? rules of conduct have allowed it to realize these principles?
This perspective helps to re-examine the practice of argument and different methodology, in a back of the everyday, as a third dimension to which institutional psychiatry would refer to situations or challenging clinical care practices ethically sensitive.
At the political project, the use of ethics is needed in a time when psychiatry combines disparate practices based in the absence of theory or of effectiveness demonstrated by experience, sometimes even on atheoretical. As if she was no longer based on no foundation, no building shared collective that guides everyday practice and makes possible theories and clashes between these theories, allowing the progress of a discipline (definition of the paradigm of G. Lanteri - Laura ).
Under the guise of science and progress, we see an order profiling programming efficiency and safety without regard to invoke the therapeutic principles underlying them were past.
Under the mask of benevolence and general lack of critical questioning about the limits of his jurisdiction, mutations profound affect psychiatry. Is it better treatment of people suffering from mental illness or is it to meet pressing social and political well-defined: treatment of social unrest and economic imperatives?
These concerns resonate with the belief shared by some scientists and the public in a scientific culture as one vector of values (relevance, effectiveness, truth), also in resonance with the requirement of insurance against all risks accompanying the increasing disempowerment of the individual. These concerns echo yet pretend to some psychiatrists to answer any questions from the madness and its impact on social order, but also posed by deviations in mood and behavior, all of daily life and society.
In this context, psychiatry biologized, while thinner in the social field as she becomes more repressive and less containers for the sick.
Thus a necessary reflection on the values that guide mental action and the scope of this action vis-à-vis our neighbors.
A multidisciplinary development ethics on political and organizational lines of psychiatry, in its aspects of care and prevention is needed.
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SUMMARY
Psychotherapy is an institutional model of psychiatric care from development, just after the Second World War recognition of the pathogenic effect of asylum - which led to the crash of the existence of the patient - and the subjectivity and singularity of mental suffering.
She advocates use of the institution in establishing its appearance is to say, encouraging a dynamic exchange, the institutionalization of the different reception areas of the patient allows it to locate or relocate in its historical dimension and symbolic.
This movement in its terms theoretical, practical and scalable across the sector psychiatry is questioned in light of the concepts organizers and the questioning of medical ethics.
It appears that his approach is consistent with the ethical requirement for its major interest in the subject aspiring to introduce meaning in his life.
In this it stands out compared to new concepts of fact and psychiatric therapy related to the development of neuroscience, the promotion of the individual citizen and of legal thought, to budgetary constraints, which in the primate approach medico-technical and medico-economic, lead to an objectification of the patient and a compartmentalization of treatment.
It is important that psychiatry operates in the continuity of the movement of institutional psychotherapy - advocating analysis and cross-institutional - an ethics by refocusing multidisciplinary research on the principles, methods and policies of care.
Keywords: psychotherapy institutional sector psychiatry, medical ethics, subjectivity, institutional analysis, cross, space research ethics.
