Between 2013 and 2017, the members of the « Collectif CONTRAST » (a group of researchers specialized in sociology, law and philosophy) have shared a common research interest in the new regulations of mental health care practices, especially regarding the use of constraint. This blog is no longer active but you will find informations regarding research projects conducted by our group : CONTRAST, SPECIALZ, REGULCAP, CAPDROITS and ACSEDROITS (see below). We also provide both academic and public resources on these issues. For more information, please contact us at: firstname.lastname@example.org – email@example.com
1 – Of Constraint and Consent : Recomposing Regulations in Mental Health Practices (CONTRAST research project) (2013-2017)
In the past decades, the principle of consent has become increasingly present in the juridical, administrative, and ethical rules regulating professional care practices in the health and in the social domains. This evolution transforms the forms of constraint in care practices as well as the meaning of its use.
Particularly salient in mental health care, these reorganizations in the regulating frame of care practices affect both the jurisdictional instances (judiciary, professional, administrative, ethical) which officially produce and implement the principles, and the actors in situation which discreetly resolve the moral dilemmas they are confronted to. These changes also redefine the frontier between the practices that are valued and the ones that pertain to “dirty work”, thus raising important societal concerns regarding the balance between the civil concern for individual liberty and the more social concern for protection.
In order to shed light on these concerns, which the social sciences literature does not adequately addresses, due to an excessive opposition between constraint and consent, the project CONTRAST focuses on the regulations of care practices. The approach adopted is transversal to public policy’s categories and observes how the juridical, ethical, and deontological formalized rules, which value the principle of consent, are applied or not in situations. The project rests on the hypothesis that regulations are found not only in the jurisdictional formulation of this principle, but also in the ways professionals account for, or keep discreet, the forms of constraint their care practices involve. To test such a hypothesis, the project combines an original theoretical approach of regulations with an extended comparison of care practices in contrasted juridical and ethical contexts.
The constitution of a pluridisciplinary team, where sociologists, jurists and philosophers collaborate on the two axes of the scientific program as well as in the empirical tasks, allows for such an ambition.
The comparative axis studies five mental health practices (listening, hygiene, restraint, dealing with personal belongings, medication), in eight fieldwork sites offering contrasted contexts for exercising constraint (hospital units, community services…) and which are regulated through various rules (healthcare, medico-social, or social institutions). The epistemological axis aims at specifying the concept of regulation, at the junction of stabilized and instituted rules, and of the heterogeneous use in the course of social life. Such a specification of the concept between the different theoretical and disciplinary traditions will reveal its value for understanding care practices.
The scientific program will first consist in two joint empirical tasks. Task 1 will lead to the constitution of a corpus of jurisdictional texts elucidating the arrangement and hierarchy between the rules that locally apply to care practices. Task 2 will establish a corpus of cases coupling observations of situated care practices with discourses on their justification. Feasibility and coherence are ensured through the implementation of a common methodology in fieldwork sites previously researched by team members.
The pluridisciplinary analysis of the data will lead in task 3 to elaborate various analytical and reflexive reports, opening to multiple publications. The reports will be discussed during the team seminar and scientific events (3 day-long seminars, 5 international workshops, 1 two-days conference: « Guaranteeing persons in vulnerable situations the capacity to enjoy and exercise their civil and political rights »). These events also participate in disseminating research results, and in fostering and stimulating debates and collaborations, both in France and internationally.
2 – The specialization of care practices involving coercion and consent in the treatment of Alzheimer’s disease (SPECIALZ research project) (2014-2016)
The “SpéciAlz” research project discusses care practices that involve coercion and their regulation. These practices are developed in specialized units for the treatment of Alzheimer’s disease occurring at home or in residential facilities. It aims to achieve three objectives.
1) The first aim is to inform Alzheimer policy makers in analyzing the scope and limits of specialization plans of Alzheimer’s care in the particular field of regulation practices involving coercion. 2) The second aim is ethical. It seeks to identify how to better respect the autonomy of those afflicted with Alzheimer in their care. 3) The third objective is theoretical. It aims to highlight the validity of a theory of regulation to take on the problems posed by the coercion inherent in the care and management of patients.
The program consist of three tasks. The first is to map rules that govern care practices involving coercion. This requires a) the acknowledgment and analysis of a legal, professional and ethical corpus b) an analysis of the administrative and legal jurisprudence concerning issues of consent, mistreatment, ant the lack of vigilance involving professionnals c) the constitution of a corpus of local application rules. The second task is to analyze the conditions of specialization of the regulatory framework relating to practices of coercion in the treatment of Alzheimer’s disease and the role of contributed actors. It will be examined through a) a documentation analysis in the professional literature b) analysis through interviews of professionals and associations in the debates resulting in the production of existing regulatory framework elements (development committee frameworks of best practices and specifications for innovative specialized units). c) observation of meetings concerning new rules (ANESM, Preparatory Committee of the Law “on the societal consideration of aging”). The third task is to draw the ways in which actors make use of rules in their daily practices and justify them. It focuses on the ethnographic fieldwork (observation + interviews) in both specialized and unspecialized services (UHR in Ehpad and ESA in SSIAD). Eight practices are observed: the choice of living accommodations, taking of meals, taking of medications, body care, travel management, financial and personal management, therapeutic activities and coercive restraint.
Three types of results are expected. Socio-legal results will be the mapping of rules governing these practices involving coercion and establishing their hierarchy and enforceability formally and in term on jurisprudence. Socio-political analysis will retrace actors who contribute through their involvement in the arena to the stabilization of the regulatory framework as it exists and its evolution in the near future. The third type of results consists of an analysis of the effects of specialization practices of Alzheimer’s care through the observation of eight care practices.
3 – Recomposing Regulations in Mental capacity Assessment and guardianship (REGULCAP research project) (2015- )
In civil law, human beings are presumed to have mental capacity to take actions and decisions on their own. However, the civil capacity (legal competence) may be partly fractured when individuals are not in position to decide for themselves and in their own interests. Under these particular circumstances and medical assessments, judicial authorities may break an individual’s autonomy and have them protected by outsiders who can act and make decisions on their behalf in cooperation with them. The French Civil Code organises this protection through two distinct provisions, called « tutelle » or « curatelle ». Common laws traditions organises this protection with guardianship.
This research aims to contribute to a better understanding of mainstream policies on vulnerability, including psychiatry, mental health, public welfare and disabilities. They also constitute an invitation to explore autonomy schemes from social and civil perspective.
4 – Support to exercise rights and freedoms as citizens: establishing forums based on the UN Convention on the Rights of Persons with Disabilities (CAPDROITS) (2016- )
The participation of persons with disabilities in the activities taking place in their communities is a major challenge for democratic life and current public policies. One of the decisive keys to such participation is the effective capacity people have to exercise their rights on the social, economic, civil and political levels, i.e., their citizenship. However, in particularly vulnerable situations where people have very little possibility of recourse, these capacities are drawn on very little, diminished or sometimes even denied. These situations apply to persons with mental health disorders and illnesses, cognitive disorders due to neurodegenerative processes or injuries, intellectual disabilities or other types of impairment.
Due to the fact that Article 12 of the UN Convention on the Rights of Persons with Disabilities provides that the legal capacity of persons must not be restricted, the Convention – ratified by France in 2010 – has set in motion a new debate focusing on the challenge to access rights in the French context. The “Capdroits” project is a contribution to this debate, launched as a follow-up to the multidisciplinary international conference (ConfCap) organized in October 2015 with the support of a significant number of institutional and non-profit sector partners. It was the difficulty people directly concerned have (persons with disabilities, mental health services users) in communicating about those conditions that would allow for the effective exercise of their rights as provided for in the Convention that led the researchers from Collectif Contrast, together with the Conseil français des personnes handicapées pour les questions européennes (French Council of persons with disabilities for European issues – “CFHE”) to design this research project. A Monitoring Committee composed of partners and a Scientific and Ethical Committee (French and International) will participate in the governance of the project.
The Capdroits project has a three-fold objective:
- Foster the participation of persons with disabilities in debates on issues which first and foremost concern them directly;
- Promote the acceptance of their contributions by relevant academic researchers and public authorities;
- Shed new and experience-based light on how these persons may exercise their rights.
5 – ACSEDROITS research project (2016- )
We assist today to an increase of the ageing population (in France and in Quebec, ⅓ of the population will have more than 60 years in 2050) along with a risk of vulnerabilisation of elderly people. To cope with this demographic challenge, States have set up legal mechanisms of protection as well as socio-medical services. These mechanisms and services rest on social rights that need to be activated. The access to these rights is rendered difficult when the cognitive vulnerability of the elders weakens their capacity to exercise their rights and to put forward their interests. This creates a series of situations in which the respect of their fundamental rights is endangered, in spite of or because of the recourse to these legal mechanisms of protection. The increase in the recourse to these mechanisms poses various types of problems, the more so as their legal foundation is disputed today. The need assessment for protection rests on dubious criteria; the control of the decisions taken and of the actions conducted for the person by others remains scarce; the respect of the preferences of the person is difficult to realize. This poses the problem of the access to their rights by the persons with cognitive vulnerability.
Project ACSEDROITS will assess whether the current legal tools and their social uses in France and in Quebec make it possible to solve or on the contrary contribute to worsen the difficulties of access to their rights by the elders with cognitive vulnerability. It will be articulated around two hypothesis: 1) the difficulties of access to the rights are reinforced by the lack of communication between social and civil rights, at the legal level (legislation, case law and doctrinal), and at the level of social uses and legal conscientiousness that persons have of their rights; 2) a better respect of the rights of the vulnerable elders implies a new delimitation of the concept of legal capacity leaning towards a procedural comprehension of the decision-making processes leading to the opening of the protection regimes, the limitation of fundamental rights and the legal imposition of care and services. To test these hypothesis, the project will be based on an interdisciplinary scientific program implying an ethnographic approach of the difficulties met by the actors, a theoretical analysis of the anthropo-legal concept of capacity, and an analysis of comparative law.
Some publications in english
- Protais Caroline, 2014, Psychiatric care or social defense? The origins of a controversy over the responsibility of the mentally ill in French forensic psychiatry, International Journal of Law and Psychiatry, 37, 17-24.
- Velpry Livia, Brodwin Paul (Eds.), 2014, The Practice of Constraint in Psychiatry: Emergent Forms of Care and Control, Culture, Medicine and Psychiatry, vol.38, n° 4, 524-526.
- Velpry Livia, Eyraud Benoît, 2014, Confinement and Psychiatric Care: A Comparison Between High-Security Units for Prisoners and for Difficult Patients in France, Culture, Medicine and Psychiatry, vol.38, n° 4, 550-577.
- Velpry L., 2008, The patient’s view : issues of theory and practice, Culture, medicine and psychiatry, 32, 2, 238-258
Some posts in english