محدودیت های فیزیکی به عنوان هولدینگ روانی: درمان بهداشت روانی برای نوجوانان دشوار و خشونت در فرانسه

The phrase “Contraindre est thérapeutique”—constraining is therapeutic— underpins the principle of numerous interventions within the field of mental health in France, ranging from traditional psychiatric units to the courthouse to violence management and prevention of dangerousness. The treatment of violence in “difficult and violent adolescents” provides a paradigmatic and revealing example of this tendency. The aim of this article is to understand how the clinical category—contenir, or “to contain”—was formed and is used. The perspective taken is that of the political anthropology of mental health and the article combines a genealogical approach of the notion with a multisite ethnographical study (conducted between September 2008 and June 2012 in three facilities for adolescent care). This study will show how “psychological holding” is used to justify “physical constraint” in the treatment of adolescent crisis and violence. Furthermore, we will see how this “dirty work”, delegated to front-line professionals (educators, social workers, nurses), is used within a moral economy of suffering that promotes care and control measures in a population largely from immigrant backgrounds, judged to be both potentially vulnerable and dangerous.

The violence of mental-health patients is a central psychopathological issue and the violence of professionals towards patients is a highly controversial topic in regards to psychiatric practices. These two aspects of the treatment of violence are most often separated out in layman’s depictions and form the basis of a very common critique of psychiatry: on the one hand, those who are mentally unstable must be stigmatised for their dangerousness and violence even if there is no proven link between violence and mental health (Elbogen and Johnson, 2009); on the other hand, the arbitrary violence of psychiatric confinement and physical containment is denounced, even though chronically ill patients exist who must be institutionally cared for and who do not fit into the ideal schemes of rehabilitation and re-integration (American Academy of Child Adolescent Psychiatry, 2002:4S). In both cases, even though violence does not affect the same population, concern stems from the same moral and legal principles: what is now intolerable is the infringement of physical integrity (Fassin, 2010). It is noteworthy that this moral tension regarding clinical practices has been the object of so little research in psychiatry or the social sciences. The link between psychiatry and social control appears to have become self-evident. Yet all depends on how “violence” is defined in this treatment: a patient’s physical agitation, for example, may justify physical intervention by medical teams. The management of crises through restraint can act as a lever to encourage strong bonds between professionals and clients, as one of the rare recent studies in a residential treatment centre for adolescents shows ( Hejtmanek, 2010:671). In France, as in numerous countries, there exists consensus-based data about containment, but in a highly paradoxical and problematic form. In two successive reports (Muralidharan and Fenton, 1996; Sailas and Fenton, 2000), the Cochrane Library concluded that there was not enough empirical evidence to allow this practice to be recommended. It is generally acknowledged to be a last-course intervention (American Academy of Child Adolescent Psychiatry, 2002:5S; Larson et al. 2008). However, several professional bodies (medical associations) (American Academy of Child Adolescent Psychiatry, 2002) or state bodies (Haute Autorité en Santé 2005a, 2005b) have put forward recommendations about the use of containment (i.e. guidelines). Traditional practices (such as surrounding the patient by a large number of nurses and the technique known in French as the “technique du belier”—or “battering-ram” technique—aimed at immobilising the patient with a mattress) have been proscribed in favour of standard methods of immobilisation (like the Canadian “Approche Préventive et Intervention Contrôlée”—“Preventive Approach and Controlled Intervention”). These recommendations result in a paradox: containing patients cannot be recommended, but means for containing them can. In short, containment exists and has to be used, but the conditions should be provided in which it can be avoided. Furthermore, even within the same country and even when the need to standardise treatments has been called for (Brown and Tooke, 1992; Siponen et al., 2012), mental-health professionals put this into practice in a large number of ways (Oudjania, 2015). The issue of the therapeutic and ethical meaning of this act underpins all these recommendations. For example, a difficult and highly discussed question is whether the psychiatrist should physically participate (or not) (Kim et al., 2013) in the act of containment. Moreover, containment constantly stands in tension with, or even contradicts, the application of new ethical principles within the field of health such as autonomy, patient satisfaction and the contractual-care relationship. For example, how can the principle of informed consent be applied during crises? More precisely, what is a “crisis” and how can it be evaluated in practice? Once again, there exists a largevariation in evaluations of the necessity to use containment, including among patients (Bowers et al. 2007).

Clarifying a word from the vocabulary of clinical practice that brings together, in France, the experience of both suffering and deviance allows us to demonstrate the “miracle” that explains both its success and its self-evidence. The word “contenir” specifically allows the daily reconciliation of the irreconcilable whilst confronting one of the major difficulties of work on others: changing a disposition by a device, i.e. making physical restraint of violence into care. The basic premise is that the “normal” psychological development of the child rests on a progressive contenance of emotions or emotional “self-control”. This “pressure-cooker” model is old and easy to find to Sigmund Freud (Schwartz, 1995): civilisation polices the savage and the madman who lies sleeping in every child in the shape of his/her dangerous passions. In our case-study, we could sum-up a new version of these old view as a clinical framework coming from Lacanian psychologists and psychiatrists teaching child psychological development to front-line professionals: According this lacanian perspective, during the child’s psychological development, the contenance of emotions is acquired by the “containing” function of the parents: the mother “reassures” by enveloping and the father “limits” by forbidding. The violent and difficult patient is the one who therefore has a deficit linked to his/her psychological development and his/her impulsivity is linked to his/her affective immaturity. The adolescent’s “acting out” is an indicator of this failure of symbolic contenance on the child’s body. The shift from contention to contenance is therefore proposed by Lacanian psychoanalysts (Legendre 1997) in order to think not only about the effect of emotional deprivation within the family unit, but also about deficiencies in internalising the symbolic order (the Law). This Lacanian theory of the deficiency of the symbolic order fits perfectly with the preoccupation with losing and re-establishing authority within French society. In response to the transgressions and violence against the adult world, strictness is expected. The respect of adults should lead to a respect of the law. Gendered conceptions of authority are summoned here: it is the “role of the father” that “refers to boundaries”. According to this perspective, the concepts of enclosure and boundaries—which refer as much to the body as to the group and to the institution (Chouvier 2002, Ciccone, 2001) – have two effects: • On one hand, the action of contenir defines a general category of the subject in mental distress: “those who suffer from a lack of contenance” (Gentis, 1997). It can be applied completely independently of psychiatric categories. “Behavioural disorders” become the target of these and the scope of this is wide: “By mental and behavioural disorders, we mean significant clinical affections characterised by a change of thought process, mood (affects) or behaviour linked with psychological distress. Behavioural disorders are not simple variations within the limits of what is “normal”, but obviously abnormal or pathological phenomena. A single episode of abnormal behaviour or a short-term mood disturbance is not, in itself, the indication of a mental or behavioural disorder. In order to be considered as such, anomalies should be permanent or repeated and cause suffering or impede one or more areas of daily life”. (Gentis, 2007). • On the other hand, this action assigns a therapeutic value to constraint and, by doing so, to sanctions: punishing is containing. The subject unconsciously seeks out punitive constraint as a means of halting his/her repetition compulsion (Balier, Grépillat, 2002). Prison, through its extreme firmness, can play an enveloping role, framing adolescents’ over-spilling emotions. Within this clinical frame, The team of professionals in charge of violent and difficult adolescents have the role of containing the suffering that is only expressed through “acting out”. They also perceive themselves in a role of parental substitution, through which the issues surrounding emotional autonomy are re-enacted. In the psychoanalytical model, parenthood is divided into functions of mothering and fathering. The institution also has the overall function of contenance. In cases when contenance fails repeatedly within the framework of treatment (as a disposition to be created by this device), different levels of physical contention can be considered in the name of psychical contenance, beginning with simple immobilisation (with communication), moving on to immobilisation (physical or sedative) in a seclusion room, and finally, extending to psychiatric or prison immobilisation and seclusion (court hearing and incarceration).