Patrick Landman
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Billet de blog 22 mai 2020

Reinventing Psychiaatry

Yesterday's world is over , reinventing psychiatry

Patrick Landman
Abonné·e de Mediapart

Ce blog est personnel, la rédaction n’est pas à l’origine de ses contenus.

Reinventing Psychiatry
The crisis situation linked to the Coronavirus epidemic and the lock down have highlighted the
importance of speaking out, listening, social ties, collective action, solidarity, the fight against
inequalities, and respect for nature. It raises the expectation, shared by all, of policies focused on
better access to public health, on the protection and well-being of individuals, and on their
But this epidemic and its management have shown the limits and sometimes the failure of the
dominant political orientations and paradigms in the field of psychiatry. These have proved in many
circumstances to be insufficient, inadequate and inoperative. And we can no longer ignore the fact
that the person must be approached in his psychological and social dimension, with his history and
in his environment. The person cannot be simply "cut up" into observable symptoms that lead to the
hyperspecialisation of professionals and the breakdown of management systems. Psychic suffering
cannot be reduced to a neuro-scientific conception, and care must not be limited exclusively to drug
treatments and behavioural programmes, based on a manual, the DSM5, originally designed for
drug trials and epidemiology, without any real consideration of the clinic.
This crisis also reveals the formidable capacity for commitment, responsiveness and inventiveness
of the professionals and teams in the field, as well as the primordial importance of taking their
experience and proposals into account.
This is the time for a reinvention of psychiatry in the image of what happened in France after the
liberation, where psychiatry turned its back on previous principles such as the centrality of asylum,
confinement, and discriminatory practices, to commit itself to a human psychiatry committed to the
city, some of which is now referred to as institutional psychotherapy.
Yesterday's world, the world before the health crisis, and its main harmful paradigms:
Health bureaucracy, conflicts of interest, scientist illusions, exclusive use of the DSM, abusive
place of medico-economics with a single managerial thought.
- The Regional Health Agencies: the health agencies have generally failed to anticipate the
measures and resources to be mobilised in the event of a pandemic, and have been powerless or out
of step to prevent and support psychiatric and medico-social institutions to enable them to provide
satisfactory health protection for patients and staff. Whatever the qualities and dedication of its
officials, the current health crisis is indicative of their bureaucratic functioning too far from the
field. In this period, what has been effective in some places has been the cooperation and mutual
respect between administrative staff and carers and the fact that administrative staff have heard and
supported carers.
- The Haute Autorité de Santé (HAS): The recommendations of this body, whose EBM credo does
not cover an absolute level of scientific rigour in psychiatry, are often interpreted by the
administration and decision-makers as stating a single truth to be applied to the letter (particularly
in the field of autism), whereas they should be relativised because of their programmed
obsolescence, and contextualised to take into account the complexity and clinical singularities as
well as environmental and social data.
- The "quality approach" and "risk management" piloted by the HAS and ANESM, under the aegis
of Certification in the health sector and Internal and External Evaluations in the medico-social
sector, which mobilise financial resources and, for the staff, in terms of working time taken away
from their presence with patients, are distinguished by a rather catastrophic benefit/cost ratio and by
their results that are largely unusable and therefore useless. The quality and risk management
approach is very selective because, for example, it does not take sufficient account of the many
studies on the long-term risks of psychotropic drugs, or the studies that claimed that a pandemic
was inevitable. Not all the protocols in this approach have been able to anticipate or organise
properly to deal with the pandemic or the expectations of users. And no one, moreover, had the idea
of opening up the evaluation reports that lie dormant in the cupboards of administrations attesting to
the inadequacies of actions based on mathematical modelling and rigid protocols, as well as on
ideological a priori.
-An administrative and accounting management that is cut off from the clinic and the realities in the
field, deaf to the creative experience of the professionals and the demands of the users. The
incoherence of public health policies and the organisation of medical-social support, which means
that systems are juxtaposed without any overall conception or reflection on their interrelationships,
leaving aberrant gaps to ensure the necessary care and continuity of care without breaks in care, as
desired by users and their families. How is it possible, for example, that it has become almost
impossible to be able to hospitalize children or adolescents in full-time child psychiatry services
when necessary? How can we tolerate waiting periods before a first appointment in a Medical
Psychological Centre or Medical Psychoeducational Centre which can frequently be longer than a
year? Finally, how can we cope with the lack of psychiatrists and child psychiatrists who leave
hundreds of vacancies?
-The reign of expertise: many "Expert Centres" have in fact demonstrated their inadequacy and
inexpertise in the current context and, by contrast, show the expertise and efficiency of the teams in
the sectors and inter-sectors of public psychiatry as well as private associative institutions, which
are in the front line of work with the population. The criteria for determining expertise and
excellence in psychiatry must be broadened and, above all, rethought, since they are based solely on
specialization around symptoms and a consensus that is more ideological than scientific and
sometimes not without conflicts of interest. Expertise, such as that of INSERM on child conduct
disorder, should also be reconsidered in their approaches and their results, which have been
invalidated by experience and by numerous studies.
-A cleavage or even opposition between disability and psychological suffering, which denies the
psychological fact, leading to an "extension of the field of disability" where any "anomalous"
subject is exposed to be considered as disabled and cannot have the right to psychological care
because it is exclusively based on rehabilitation techniques. This separation between disability and
psychological suffering must be qualified, because it is necessary to highlight the fact that mental
pathologies lead to sometimes severe handicaps and that, conversely, the persistence of
disadvantages in social interactions contributes to the establishment of psychopathological
mechanisms that are sometimes very restrictive.
-Wide industrial lobbying of the Ministry of Health and the Secretariat for Disabled Persons,
particularly by the pharmaceutical industry or influential groups claiming to represent users and
their expertise, which dictate their choices and orientations to the public authorities. Conflicts of
interest are the rule here in a context of public/private permeability and the ubiquity of the field of
A categorisation of patients under the exclusive control of the DSM, which multiplies "disorders"
with blurred limits and no real clinical validity, from a superficial scientific perspective, in line with
the expectations of the pharmaceutical lobby, generating false epidemics (such as ADHD for
example), and leading to over-diagnosis and above all over-medicalisation, of children in particular.
The reference to the DSM impoverishes clinical assessment and leads to category-based care, which
is costly in terms of health economics and, above all, loses sight of the individual person in his or
her singularity and as a whole.
Inventing tomorrow's psychiatry :
Let's start by evaluating the real contribution and benefit of the systems set up by the public
authorities over the last twenty years: the ARS, the HAS, the National Agency for the Evaluation of
Social and Medico-social Establishments and Services, the Maison des Personnes Handicapées, the
Expertises, and the organisation of health and medico-social structures. And let us redeploy in a
more useful way the unnecessarily captive means of financing of these inadequate structures, whose
cumbersome nature hinders innovation, and which ultimately prove to be outdated because they
have exceeded their mission and have sought too much to hinder the action of the carers, to
dominate them or to dictate their conduct. Let us call for an end to the use of administrative bodies
and their structures against carers.
-Let us continue by re-establishing the plurality of approaches and conceptions without opposing
them to each other and by moving away from single thought. To do this, it is the training of future
professionals that must guarantee an education that is open to this plurality of approaches and
theoretical references as well as to critical rigour; and it is also the means to support research in its
diversity. Let us stop prohibiting scientific debate when so few of the results of experiments
presented as evidence are in fact replicated. The non-partisan state must guarantee the freedom of
research that is indispensable to a dynamic of health democracy.
-Let's give patients, their families, users, all their representatives, as well as professionals and their
inventiveness their rightful place in order to put in place care that truly cares about better living. We
can think here with the contributions of critical psychiatry, post-psychiatry or community
psychiatry as they have developed in some Anglo-Saxon countries, and also psychoanalysis which
remains an essential reference for listening to patients, alleviating the suffering of teams regularly
confronted with difficult or unusual situations and sometimes violence.
It is time to break with the single scientist way of thinking while remaining open to scientific
advances, with the dogmas and financialization that dominate our institutions, with the hold of Big
Pharma and the exclusive biologic-behavioral orientation, and with the domination of the DSM.
It is time to give back its full place to the word of the subjects, to the human being, to commitment
in the city, to citizenship.
Stop DSM
Paris France 05/13/2020
Translated with (free version)

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