This article is part of the following series: Foreign correspondents
We’re very pleased to reintroduce the “Foreign Correspondents” section of Somatosphere. The aim of the section is to provide contributors and readers of Somatosphere with a forum for recent, important works that appear in languages other than English – as well as announcements about conferences, journal issues, and other related projects. We proudly present the section’s first installment, a review of Livia Velpry’s Le quotidien de la psychiatrie: sociologie de la maladie mentale (“Day-to-day Psychiatric Practice: Sociology of Mental Illness”), reviewed by Lydwine Verhaegen. We hope you enjoy the review and we look forward to many more contributions to the section in the future.
– Stephanie Lloyd and Todd Meyers
Le quotidien de la psychiatrie : sociologie de la maladie mentale (“Day-to-day Psychiatric Practice: Sociology of Mental Illness”)
Author: Livia Velpry
Publisher: Armand Colin, “Sociétales” Collection
Date of publication: 28 April 2008
There is an abundance of works and reports on the crisis of public psychiatry and on the increasing demand for psychiatric care, many of which tend to conflate mental health and psychiatric disorders. However, as Alain Ehrenberg (see also La société du malaise, 2010) asks in his introduction to this book by Livia Velpry, what do we really know about ordinary psychiatry, that is, the lives of those with mental illness, and serious psychiatric disorders? Or about the new types of patients who combine psychological and social problems, as well as about the professionals who treat them? Before proposing remedies, what is needed first and foremost is a description, which is precisely the sociologist’s objective.
Livia Velpry’s book is an analytical report based on a very lengthy observation of patients and professionals frequenting a community-based-psychiatry (secteur) medical-psychological centre (CMP) in Paris. Nowadays, the total institution – the asylum – described masterfully by Erving Goffman (Asiles, 1968), is no longer the only form of psychiatric treatment in much of the West. The individual patient is thus left to be his/her own agent of change and to aim for autonomy in the most open environment possible. But, mental illness calls into question the individual’s capacity as a reasonably rational human being. So, in concrete terms, what really happens?
The first part of Velpry’s book describes sectoral psychiatry – France’s pioneering version of community psychiatry, established in the 1960s – in the complex present-day landscape of psychiatry in France, where sectorization increasingly situates the public management of madness in society in patients’ local communities. The author describes the activity of a CMP -the outpatient mental health clinic in each catchment area -, and its functioning and teamwork, which are marked by a tension between accessibility and continuity of treatment that runs through all of psychiatry today. She analyses practices such as teamwork, a mode of organisation shared by similar centres in other countries, and examines procedures for patient admission and treatment. Her underlying question might be: How does an individual life become a psychiatric case?
The socio-demographic characteristics of the people who turn to a CMP for assistance are discussed briefly, perhaps a bit too summarily because understanding these characteristics is one of the challenges of public psychiatry today. Psychiatry has in fact always maintained a special relationship with society and patients suffering from severe disorders are often dependent on social welfare. The author suggests that the CMP produces two distinct types of populations: “psychological cases” in which the social aspect cannot be ignored and “psychiatric cases” (usually more severe) defined by previous follow-up and specific behaviour toward psychiatric institutions. By using this terminology, Velpry carefully avoids definitions based on psychiatric diagnoses, which is one of the key strengths of her analysis. She relies instead on contextual understanding of patients.
In the second part of her work, Velpry distinguishes three styles of action by professionals, each corresponding to their expectations of patients’ gradual development of the capacity for autonomy, thus showing the patient’s ideal progression. First is the “laisser faire” (hands off) style, i.e. counselling a patient in great distress without asking him or her to commit to a therapeutic relation. In this case, the patient is deemed to have little autonomy and limited capacity to become autonomous. The second style of action is that of “faire pour” (doing for), where the patient is considered able to accept the therapeutic relation but unable to control his/her illness or to make decisions judged by the worker to be “correct”. The objective in this case is to bring patients to a point where they can act on their own. The third style is “faire-faire” (doing with, or having the patient do), in which the patient manages to act independently to negotiate objectives and the terms of treatment and little by little become autonomous.
It is in the negotiation with professionals and the illness that the patient’s capacity comes into play, along with his/her ability to develop autonomy, creating the distinction in this typology. This part of the work is illustrated with the case of “associative apartments”.
The author also explores the experience of mental illness, and again as Alain Ehrenberg notes, speaking of experience is tantamount to describing mental illness as a system of relations in which the illness is shared asymmetrically among all the players. And once again, while not objecting to psychiatric nosology, Livia Velpry does not resort to psychological concepts. As described earlier by Erving Goffman and Sue Estroff (Making it Crazy: An Ethnography of Psychiatric Clients in an American Community, 1978), she takes the epistemological stand that the patient must be understood as a full-fledged player acting in a universe of given constraints. From this, the sociologist must be able to answers the question: which individuals are seeking which solutions to which problems?
The third and last part of the work is based on the patient’s point of view. Velpry reviews the literature on the subject (e.g. Lovell A. M.,1996, “Mobilité des cadres et psychiatrie ‘hors les murs’”, in Joseph I. Proust J. [dir]. La folie dans la place) to answer such questions as: What does it mean to be a psychiatric patient? How are the lives of the persons concerned organised and what is their relationship with psychiatry? She then explores these questions by analysing 18 in-depth interviews with patients, borrowing from Goffman’s concept of moral career the idea of a breaking point that marks the entry into a state of mental illness. She describes the progression of entering psychiatric treatment where the hospital is just one place of treatment among others and does not necessarily lead to a break with external socialisation. In the composition of new forms of psychiatric pathways, the range of resources available to patients plays a major role in the psychiatric career of the patient. More than age, it is the point in the individual’s life at which psychiatric care intervenes that differentiates the pathway and the relationship built with healthcare providers.
Velpry also relies on the concepts of processes and affiliation defined by Albert Ogien (Le raisonnement psychiatrique, 1989) to distinguish users’ profiles. She uses “distanced cooperation” with psychiatry to refer to situations in which negotiation with individuals is prioritized, especially with patients who have a recent history with psychiatric care, who can draw on other resources. Such persons, Velpry shows, always try to preserve their control over the relationship with psychiatry with the aim of freeing themselves from it in the long term. Those who engage in “integrated cooperation” with psychiatry make it a central resource in the organisation of their lives. They often have a longer psychiatric history and do not consider themselves capable of freeing themselves from the psychiatric institution. They nonetheless manage to maintain external social interactions. This analysis has the virtue of raising a crucial issue – somewhat neglected today – of psychiatric chronicity and dependence.
In this important work, Livia Velpry gives precedence to field work leading to problem solving rather than questions. Such strategic and pragmatic analysis, as practiced by Erving Goffman and continued today by the author, offers a more operational approach to understanding contemporary psychiatric practices and the universe of patients than did radical criticisms of the institution like those of Michel Foucault (Histoire de la folie à l’âge classique, 1964). Foucault’s criticisms have had a salutary effect on practices in the field of psychiatry but little impact on sociological theories when it comes to understanding actors’ behaviour. Livia Velpry applies the anthropological principle that the native is always “right”, thus avoiding a position of power over the voice of those without power.
Although there is a great deal of discussion of depression and the destigmatisation of mental illness nowadays, the author has the merit of placing the emphasis on serious mental disorders. In Europe, the latter rarely rises to the fore of public concerns, except when a tragedy brings them back into the focus of public attention. But if depression and mental health are trivialized today, the same cannot be said for the core group of psychiatric patients, who suffer from severe disturbances that last a lifetime and seriously handicap their existence. This should affect us all.
Velpry’s book has the value of describing this reality in all its diversity in an innovative way while presenting an overall perspective of the health system and society. It also engages questions of autonomy, capacity and dependence, which the author considers vital for the coming years, be it in the case of ageing, disability or chronic illnesses. The scope of this book therefore goes well beyond the description of the universe of psychiatry in the strict sense, another of its merits. This work is recommended reading for practitioners and researchers, as well as for anyone involved closely or less so with contemporary psychiatry.