France

ATTENTION : First draft before submission France, France is a unitary semi-presidential republic and a member of the European Union. On 1st January 2012, the country had a population of 65.3 million. In 2010, it had a very high Human Development Index (HDI) of 0.872. This figure notably takes into account French life expectancy, which is one of the longest in the world. Created in 1945, the “sécurité sociale” is a cornerstone of the French social protection system. The institution’s mission is to provide financial assistance to its beneficiaries when they encounter costly life events. The health care arm (that includes pregnancy, disability and death) is thus a model of “Universal health care” and funds a substantial portion of the health care system, with the rest falling to private insurance, often through non-profit mutual insurers. The number of doctors per 1,000 inhabitants (3.22 in 2008) is one of the highest in the world. In 2010, the WHO concluded its global evaluation of health care systems by underlining that France provided “close to best overall health care” in the world. The French mental health care system is organized within this framework, as are the main social sciences studies focusing on its dynamics. Mental Health System After the Liberation, the French “désaliéniste” movement of deinstitutionalization sought to bring both patient and treatment back into society. In 1952, at the Hôpital Sainte-Anne in Paris, Jean Delay and Pierre Deniker showed that chlorpromazine (Largacril® or Thorazine®) was efficient in schizophrenic patients. This therapeutic revolution of international scale launched the psychopharmacology of neuroleptics (1955) and provided support for the deinstitutionalization movement. The French mental health care system progressively became structured around the principle of “secteurs” (sectors) – an official policy of the administrative organization of French psychiatry. A “sector” is a tool for administration and health management, focusing on a delimited geographical zone (i.e. the sector) of approximately 70,000 inhabitants. In 2003, there were 817 general psychiatry sectors and 321 infant-juvenile sectors. The central service is the Centre MédicoPsychologique (CMP – community mental health center) where a multidisciplinary team provides prevention, early diagnosis, continuity of care between inpatient and outpatient treatment, and follow-up care. In 50 years, the number of hospital beds has been cut in half. And yet paradoxically, the “sector” remains an antenna of the Hospital. There is great disparity across the country in terms of the distribution of sectors and the means allocated to each one. In 1968, psychiatry became a separate discipline from neurology. Thanks to Jacques Lacan, psychoanalysis rose substantially and 1 became permanently established within psychiatry, despite episodes of the “Freud Wars” between 2003 and 2010. In 2005, France had the highest density of psychiatrists in the world (13,600). It is the most frequent medical specialization (13%). However, the profession is ageing and there is great geographical disparity between the North and the South of the country – Paris offers an exception with three times as many privately practicing psychiatrists as the national average. Mental disorders are the second most frequently attributed diagnostic category in France. Ranging from distress to psychiatric pathologies, mental disorders are estimated to affect 10 million people. In 2005, they represented 10.6% of health care expenditure (11.4 billion Euros). France is one of the countries in Europe with the greatest incidence of depressive disorders and has a very high suicide rate (17 in 100,000). Paradoxically, according to the available data, only a minority of people suffering from depression use the services available and receive adequate treatment. And yet France is the greatest consumer of antidepressants in Europe and the second greatest consumer of alcohol. Tobacco and cannabis are also very prevalent amongst 18-25 year olds. Social Studies of Mental Health Social Studies of mental health care in France remain relatively rare in comparison with Great Britain or the United States. There are, of course, the major works by sociologist Émile Durkheim on Suicide (1897) and philosopher Michel Foucault on the history of madness (1961), however they have not given rise to the development of a specific field. It is nonetheless possible to distinguish three main periods between 1959 and 2007 in research devoted to the mental health care system: Between 1959 and 1968, sociologist Roger Bastide (1898-1974) and those around him studied social correlations of mental illnesses. The dominant method was statistics and the research object – mental illness – was provided by psychiatry without any critical discussion. In 1959, along with psychiatrist Henri Baruk, Bastide founded the Centre de Psychiatrie Sociale (Center for Social Psychiatry) at the École Pratique des Hautes Études (EPHE) but it was ethno-psychoanalysis, around Georges Devereux’s work, that gained relative visibility. Literature reviews of Anglo-Saxon research began to appear and ethnographic studies were carried out on the fringes of mainstream research by psychologists. Between 1968 and 1989, psychiatric institutions met with criticism. Goffman’s Asylums was translated in 1968 and published with a preface by Robert Castel, who used a genealogical method inspired by Michel Foucault to examine the transformation and expansion of psychiatric social control, particularly in his book The Regulation of Madness. The 1980s saw the development, still on the fringes, of ethnographic studies of psychiatric work, psychoanalysis and psychotherapists. Between 1990 and 2010 came a renewal of research in the field. Questions now focused on the social stakes of mental health: in 2000, Pierre Bourdieu looked at the social production of 2 suffering; Ian Hacking – appointed to the Collège de France in 2000 – focused on the history of psychiatric classifications; Alain Ehrenberg, who founded the Centre de Recherche Psychotropes, Santé mentale, Société (Research Center on Psychotrops, Mental Health and Society), considered addiction and depression; and in 2009, Didier Fassin and Richard Rechtman tackled trauma and victimhood. This period also saw many doctoral theses in the social sciences advocating an ethnographic approach. Samuel Lézé ENS de Lyon (France) See Also: Durkheim, Emile; Foucault, Michel; Lacan, Jacques Further Readings Bourdieu, Pierre, dir. The Weight of the World: Social Suffering in Contemporary Society, Stanford University Press, 2000. Bromet, Evelyn, and al. “Cross-national epidemiology of DSM-IV major depressive episode”, BMC Medicine, 9, 90, (2011). Castel, Robert. The Regulation of Madness: The Origins of Incarceration in France, University of California Press, 1988. Codefy, Magali, dir. La prise en charge de la santé mentale (Mental health service), Paris, La documentation française, 2007. Coffin, Jean-Christophe. “ 'Misery' and 'Revolution' : the Organization of French Psychiatry, 19101980”, Gijswift-Hofstra Marijke, ed. Psychiatric Cultures Compared, Amsterdam, University Press of Amsterdam, 2005. Ehrenberg, Alain, The Weariness of the Self: Diagnosing the History of Depression in the Contemporary Age, Montreal, McGill-Queen’s University Press, 2010. Fassin, Didier, Rechtman, Richard. The Empire of Trauma. An Inquiry into the Condition of Victimhood, Princeton, Princeton University Press, 2009. Foucault, Michel. History of Madness. London, Routledge, 2006. Lézé, Samuel. L’autorité des psychanalystes (The authority of Psychoanalysts), Paris, Puf, 2008. Lézé, Samuel. “An exploration of the possibility of a sociology of mental health: An historical epistemological examination of the subfield in France”, Journal of mental health, 16, 3 (2007). Verdoux, Hélène and Tignol, Jean. ‘Focus on psychiatry in France’, Br J Psychiatry, 183, (2003). 3