Qui prend soin du réseau ? Essai d’actualisation du paradigme de la psychothérapie institutionnelle dans le système de santé mentale français

Abstract

In this paper, we wish to actualize the French institutional psychotherapy (IP) paradigm in the light of the practices and discourses of today's mental health professionals. Indeed, though IP started in 1952 as a sociology-inspired theory of practice in mental health institutions, it soon became an interdisciplinary theory and method for pluriprofessionnal teams working with people suffering from mental illnesses, using psychoanalytic, political, sociological, phenomenological and mathematical concepts to create an original corpus. Our research unfolds in two different types of results: first, from a document analysis we conducted on the writings of the major authors of the IP movement from the 1950's to the 1980's, eight “operational concepts” or “operators” emerged, which aim to answer the main ethical questions relating to everyday practice with people suffering from mental health disorders. These operators are underlying principles of the organization of care and teamwork: 1° distinguishing between status, role and function; 2° considering daily life as having a therapeutic coefficient; 3° doing things together as the prime relationship structure between users and carers; 4° considering decision-making as a collective function enacted during multiprofessional meetings; 5° freedom of circulation; 6° welcoming the singularity of patients; 7° trying not to further alienate them; 8° and finally “grafting openness” as a way to prevent the withdrawal of patients from their peers, and the withdrawal of the institutions away from the community. Our second corpus has been gathered through a field study we conducted in fourteen sanitary and medico-social institutions, in which we interviewed 85 mental health professionals. We transcribed, anonymized and analysed the semi-directed interviews and compared them to the eight “operators” of the IP movement, which emerged, from our document analysis. Our research first showed the current situation of the French mental health field has created a series of risks and opportunities for the sustainability of the IP paradigm, most notably a growing concern for workers’ Quality of Working Life, the influence of the deinstitutionalization paradigm, and the defiance surrounding the term “institution” itself, despite its rich and plural meaning. Our main results, however, relate to the degree to which the operators are still relevant and useful today. We found most of the operators still represent important questions and problems mental health professionals deal with in their day-to-day practice with people suffering from mental health issues, be it the flattening of hierarchies within teams, the use of day-to-day activities as a means for therapy, the creation of clubs and common projects, the need for team meetings and shared decision-making, the growing respect for freedom of circulation as a constitutional right, the need to welcome users as they are, the questioning of professional ideals of care and recovery or the maintaining of partnerships between different institutions. We therefore affirm the use of the IP paradigm could help professionals reflect on their practices and empower themselves.