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Contraindre pour soigner ? Les tensions normatives de l'intervention psychiatrique après l'asile

Abstract : The exercise of coercion has always been at the heart of the accusations made against psychiatry, sometimes by the professionals themselves: accusations of arbitrariness, abuse and violence. At the same time, it is defended in the name of protecting people themselves or even as part of therapeutic models. The study follows the different constraint practices, the critical variations to which they are unequally exposed and the forms of regulation to which they are subject. It explores the persistence of coercion within a psychiatry that has now undergone profound changes: mainly free and extra-hospital care, a sharp reduction in the length of stay. It studies it through two dimensions: coercive practices themselves, which are repositioned amidst all professional interventions, and institutional, legal, architectural and spatial arrangements, which crystallize a certain trade-off between normative tensions between care, security and freedom. In the first part, the French legal framework is put in a historical perspective of since 1838 in its articulation with the transformations of institutions and care modalities. It allows to highlight the way in which certain types of constraint are problematized and legally regulated. While hospitalizations without consent are seen essentially as an infringement of the freedom to come and go, other forms of coercion (the use of isolation rooms or straps, drug treatments, intra-hospital restrictions, etc.) are subject to weaker regulations or entrusted to the arbitrator of doctors invested as a moral figure within the institutions. The model of "therapeutic isolation" within the development of "moral treatment" by alienists supports the legitimization of a constraint "for" care. A second part is devoted to the analysis of the economy of intra-hospital constraints (location of services, organisation of traffic and rhythms), based on the ethnographic study of a sector (spread over almost two years: hospitalisation service, 6 months, reception and crisis centre, 3 months, inter-institutional meetings with local actors), shorter observations of other services (hospitalisation and psychiatric emergencies, 2 months) and interviews with psychiatry professionals (n=61). This section highlights how regulations (in the name of "quality", fundamental rights, professional standards, etc.) mark the variations in criticism of the various constraints. Professionals themselves make distinctions between legitimate and illegitimate coercion and develop skills in order to prevent or at least limit the violence of their practices, to defuse situations where coercion may be necessary and to obtain, if not consent, at least the "goodwill" of hospitalized persons. The plurality of uses of coercion "in the name of care" (soothing-containment, maintaining framework order, preventing running away) is shown from the example of the isolation room. A third and final part deals with these moments of transition, which are the decisions of hospitalization without consent (HSC) and discharge, in the context of care that is now mainly out of hospital (post-asylum) where precisely a certain number of people living with serious psychological disorders experience repeated hospitalizations without consent. The analysis of the available statistics, despite the limitations of the sources (series breaks, response rates) linked to their production challenges, reveals a strong territorial heterogeneity in France in the use of hospitalizations without consent. This work shows that hospitalization without consent actually covers a series of decisions from the initial use of psychiatry to confirmation and then prolongation of hospitalization. It highlights the importance, beyond the clinical evaluation of individuals, of the interdependence of the uses of coercion with the local policy of the organization of health care systems (location of services, organization of emergencies, population basin served, existence of a mobile team, etc.) in a given territory. The analysis of HSC files and interviews with psychiatrists also reveal the variability of the forms of "danger" that these decisions are supposed to prevent: vital risk for oneself, violence on others, but also breach of care, risk of loss of housing. These decisions are part of a management of the flow of people hospitalized in services limited in number of places, but also in a composition of the group of patients present at a time. If it seems "normal" to professionals to receive misconduct in psychiatric hospitals, they share between them a sharing between those who have a legitimate place in psychiatry (qualified pathologically) and those who would not fall within the scope of pathology (qualified morally). The limits to coercive professional intervention then come from three sources: external regulations (law, quality,...) with low effectiveness, self-regulation by professionals marked by strong reflexivity, but also obstacles to the possibility of intervention.
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Delphine Moreau. Contraindre pour soigner ? Les tensions normatives de l'intervention psychiatrique après l'asile. Sociologie. Ecole des hautes Etudes en Sciences sociales (EHESS), 2015. Français. ⟨NNT : ⟩. ⟨tel-02151955⟩



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