Vers « la fin de la psychiatrie » ? Analyse épistémologique

Psychiatry is now confronting a critical movement, which predicts not only its « collapse », but also its « end » and even its « death ». After a reminder of the facts, this problem is approached by an analysis of the components and of the structure of psychiatry. First all the domains constituting psychiatry, their internal and external links, and their general coherence are reviewed. An analysis of psychiatry's diverse components shows that the nature of mental trouble is not restricted to mental suffering only; it is also necessary to consider the role of biological factors, of representations, of the milieu, and of the tools for thinking, as well as that of the institutions and of the treatments which have evolved over time. Psychiatry is subsequently considered as a structure which has evolved from its roots, its conceptual evolution, and the crises it has overcome. It is thus possible to show the limits of present assertions and to deny the exclusive role of neurosciences or of sociology. The actual forms of psychiatry are certainly open to criticism, but this does not imply the disappearance of this discipline, the specificity of which rests not only on its objects of study, but also and especially on the nature of its procedures aiming at precising them more precisely.     

Parcours de soins et expertises psychiatriques pré-sentencielles : une étude descriptive au centre pénitentiaire de Château-Thierry

ContextThe high prevalence of psychiatric disorders among people in prison is well documented, and several hypotheses have been proposed to explain this overrepresentation. In France, the decrease in the number of people found by the judge to be not criminally responsible on account of mental disorder after a psychiatric expertise could play a crucial role. The Château-Thierry prison is a high-security correctional facility where prisoners whose integration into a “standard” prison is complicated because of behavioural problems, reside. We conducted the first study to describe the judicial and healthcare trajectories of people incarcerated in this facility.MethodAll the people incarcerated in the Château-Thierry prison between May and September 2019 were included in this cross-sectional study. In addition to sociodemographic characteristics, data on the psychiatric care before and during incarceration as well as information on the judicial and prison history were collected. We also analyzed all the pre-sentencing psychiatric reports in order to collect the degree of discernment determined by the psychiatrist expert for each included individual.ResultsSixty-eight (97%) of the 70 people detained at the Château-Thierry prison during the study period were included and 92 pre-sentencing psychiatric reports were analyzed. The population studied was exclusively male, with an average age of 40 years, low socio-economic status and frequent criminal history (79%). About half of them (46%) had already been hospitalized in a psychiatric community hospital prior to incarceration, and 79% have been hospitalized in a psychiatric facility during their incarceration. Disciplinary sanctions were frequent (72%) as well as convictions for offenses committed while in prison (57%). When at least one pre-sentencing psychiatric report was carried out (29 persons had a single psychiatric forensic evaluation and 27 ones had multiple evaluations), at least one psychiatric expert had concluded to a diminished (but not lack of) criminal responsibility in almost half of the cases (44%).ConclusionThis study shows the extent to which people incarcerated in the Château-Thierry prison are affected by psychiatric disorders. It also highlights the difficulties of coping with the prison environment for people suffering from psychiatric disorders. Finally, it raises the question of the lack of diversion programs for the individuals in France with mental health problems whose responsibility has been considered as full or diminished.     

Risque et existence : un éclairage du risque thérapeutique en psychiatrie

Risk management is a principle of political action, an organisational strength that keeps increasing in our modern societies. In medicine, the benefit/risk ratio precedes any therapeutic treatment. Psychiatry also confirms this trend. It is undoubtedly desirable in many aspects. However, the notion of risk cannot be understood under the unique and technical perspective of an undesirable event to anticipate. Risk management is not limited to a predictive and preventive refinement, but disturbs the situation of the individual in its environment, granting him a new responsibility, changing his possibility to live in the world and take shelter in it. Beyond these anthropological aspects, from a phenomenological psychiatry perspective, the matter of risk is closely related to the question of authentic existence. Thus, the risk not only appears under the perspective of an undesirable event, but also as a founding instant of the existence in the world and within oneself. Therefore, the therapeutic project of psychiatry could also intend to recognize and promote a certain type of risk, the risk of any existential commitment. The therapeutic risk in psychiatry thus takes a new ontological dimension.     

Evidence isn't enough: some comments from the daily practice of acute psychiatry

Randomised clinical trials (RCTs) generate knowledge that is useful in some situations but is of limited value when it comes to dealing with complex problems in clinical practice. By means of arguments drawn from acute psychiatry it is argued in this paper that a) the preconditions under which an intervention seems to work in a trial are all too often not met in the clinic; b) the problems that evidence-based interventions seek to solve tend to be unlike the problems that clinicians encounter in a day-to-day basis; and c) it is often impossible to ascertain the parameters against which the efficacy of intervention can be measured. Therefore, acute psychiatry, like all the other branches of healthcare, urgently needs not only information about 'proven efficacy' via RCTs but also other kinds of information derived from other methods of research.     

Moral responsibility, consciousness and psychiatry

This article discusses the connection between consciousness and responsibility. Moral responsibility plays a crucial, but often implicit role in psychiatry in that it is often a therapeutic aim as well as an important evaluative concept. This article explains one of the more influential 'psychological' theories of moral responsibility, developed by Harry Frankfurt. In the second part of this article, a modified version of this account is applied to a range of psychiatric phenomena.     

La psychiatrie et les disciplines extrinsèques. Ouvertures et compositions

ObjectivesPsychiatry as a discipline is oriented towards the other and towards otherness; not only that of the patient and of their psychological issues, but also for the alterity of external knowledge. Recognizing its own limitations and its inability to think alone, psychiatry, whose specific knowledge is undoubtedly quite limited, has since the beginning turned to other disciplines. This article does not try to propose a new model likely to articulate this conceptual heterogeneity, but tries to understand how this movement of opening towards other disciplines is carried out. Psychiatry undeniably finds a richness in this, but does not its subservience to currents that are external to it risk accentuating its dissolution and making its identity disappear?MethodBased on the distinction proposed by G. Lantéri-Laura between intrinsic disciplines (i.e. clinical disciplines such as neurology, psychoanalysis) and extrinsic disciplines, which use a theoretical elaboration that owes nothing to clinical engagement with subjects (such as anthropology, history, or linguistics), this article will endeavor to show the contribution of extrinsic disciplines throughout the history of psychiatry, using a number of specific cases.ResultsThis article describes several ways in which psychiatry is linked to extrinsic knowledge, focusing more specifically on the human and social sciences and on history. Firstly, we study the movement by which psychiatry seeks support for its practice, an ethic of care, and even a critical ‘third eye’ that can offer it this perspective on a practice that is often decried. Secondly, this study proposes to examine the extent to which psychiatry, through the knowledge that it isolates concerning the question of madness, opens up by itself to a questioning of humanity that can be taken into account by other disciplines. Sociology shows, in particular, how clinical categories can be linked to the prejudices and ideals of a culture and an era. History shows how an event such as Pinel's liberation from chains can benefit from historical interpretations, the meanings of which are never exhausted.DiscussionPsychiatry is inspired by other knowledges, but this borrowing is often based on displacements that reflect the need to adapt to clinical issues. This extrinsic knowledge is never imported without transformation and without some infidelity.ConclusionRe-examining what is most obvious, questioning what seems most customary, these are the benefits that psychiatry can obtain by choosing to decentralize and to call upon disciplines extrinsic to the clinical. The inclusion of the human and social sciences in the understanding of psychological disorders is now well established. The dialogue that results from the meeting of heterogeneous disciplines is not intended to lead to a consensus. The clinical practice of psychiatry retains strong specificities linked to the exercise of the encounter with mental disorder. The resulting knowledge is irreducible to other disciplines. The psychiatric act is based on a responsibility incumbent on the clinician alone, irremediably divided by the issues he or she must face.     

Ethical issues in the prevention of suicide in prison.

OBJECTIVE: The aim of this paper is to discuss ethical issues that arise in the care of suicidal patients within a prison context. Such a discussion provides a suitable framework for exploration of the broader question of how coercion may be exercised by psychiatrists in a morally justifiable, as opposed to abusive, manner. METHOD: Literature relevant to the abuse of psychiatric power is reviewed. The means for immediate containment of highly suicidal patients in certain prison contexts is described and the paucity of relevant empirical research literature relating to this is identified. A framework is proposed to assist clinicians in making an ethical evaluation of coercive interventions that is applicable not only in the prevention of prisoner suicide, but also in the practice of psychiatry as a whole. RESULTS: Due regard for the moral dimensions of the relationship between psychiatrist and prisoner has the potential to radically transform the way the exercise of power is subjectively experienced by each of them. CONCLUSION: Coercion can be exercised by psychiatrists within an ethical framework which is not abusive. There will always be a risk that coercion will become an unhealthy habit of life within which the psychiatrist feels too comfortable.     

« L’avis psy ». Quel avis, pour quelle demande et pour quelle éthique ?

The response of the psychiatrist to a demand of “psy advice” varies according to its theoretical orientation. An ethical structure corresponds to each practice. On the contrary, if this response becomes the condition of a possible statement of the complaint, then it is possible to define the ethics of psychiatry as this kind of obligation where I answer ‘in front of’ the other. Inspired by the work of Levinas, this ethics of this response defines the ethics of psychiatry.     

Évolution des attentes et des représentations en clinique dans les rapports entre psychiatrie et justice

Relationships are difficult between psychiatry and Justice. Psychiatry is regarded either as an enemy of freedom or as too liberal. One criticizes it for its disengagement from the hospital and for its responsibility regarding a so-called excess of hospital beds. The responsibility of Psychiatry in the accumulation in jails of mental patients is often denounced. However, since the birth of the diagnosis of mental disorders, psychiatry evolves by extending its field of competence beyond the recognized psychoses to an operative clinic in the borderline disorders. Our societies are not satisfied and ask the psychiatrist to be present in any violence and with each delinquent. Crime and psychiatric disorders are regularly confused. Are our societies sick of their fears while confusing in its representations crime and madness, care and punishment?