French president proposes repressive “reform” of mental health care

By Jacques Valentin
22 December 2008

A December 2 speech by French President Nicolas Sarkozy during a visit to the Erasme Hospital, which specialises in mental health, has aroused grave concern among mental health specialists. The French Ligue des droits de l'homme (Human Rights League) has issued a protest against his proposals.

The speech signalled an attempt by the president to seize on a tragic but isolated incident to expand his repressive “law and order” agenda.

In his speech at the hospital, located in Antony, near Paris, the French president made proposals that he linked to the tragic death by stabbing of a student in Grenoble last month by a mental patient who had gone missing from Saint-Egrève Hospital. The patient had been on an outing in the park, which was part of his treatment. In September, because of the favourable development of his mental condition, he had gone on to twice weekly outings.

Sarkozy questioned the hospital’s efforts to reintegrate people into the community. “There is,” he said, “a person—the future murderer—who had already committed several very serious acts of aggression in and out of hospital. This is an obviously dangerous person, who nevertheless had the right to two outings per week. I hear it said that nothing indicated that this person could strike again, and nothing had been done to enhance his surveillance.”

He continued: “Potentially dangerous patients must be under heightened surveillance so as to prevent a possible attack. And you know very well that patients who may have been in a stable state for some time can suddenly become dangerous.”

According to press agencies, the day after the murder in Grenoble, Sarkozy had called together Justice Minister Rachida Dati and Minister of the Interior Michèle Alliot-Marie to “examine all necessary measures to avoid such a tragedy being repeated.” He proposed a reform of hospitalisation of mental patients.

According to a press release issued by the president’s office, the reform would aim to “better supervise time out of the hospitals” and “improve the supervision of patients likely to represent a danger to others, within the framework of creating a national database of obligatory hospitalisations.” The press release added that the reform would seek to “clarify the allocation of administrative duties and competence in the management of these cases.”

Four days after the death of the student, the director of the psychiatric hospital where the patient was being treated, Michel Gellion, was suspended from his job in accordance with a recommendation by the minister of health, in advance of a report demanded by the General Inspectorate of Social Affairs (IGAS). This suspension has evoked vigorous protests among health care providers.

Jean-Louis Bonnet, director of the Regional Hospitalisation Agency, told Le Figaro, “The decision was taken by the National Administrative Centre, a body administering hospitals in the name of the Ministry of Health.” He has appointed an interim replacement director. Libération also reports that the local préfet—“guilty” as well of having authorised the mental patient’s outings—has also been sacked.

Sarkozy’s proposal incorporates provisions of the Delinquency Bill drawn up by the president when he was minister of the interior, including the creation of a national registry of compulsory confinements. The mental health section of the bill was withdrawn when it was passed in 2007 as a result of protests from psychiatric professionals and associations. (See “France’s delinquency bill: A step towards totalitarianism)

Sarkozy’s speech in Antony went even further in its repressive implications. The president called for “a security plan for psychiatric hospitals” to “better monitor entries and exits from hospitals and prevent people going missing.”

He said, “When a patient who is under obligatory hospitalisation leaves the perimeter permitted by his doctor, the hospital team must be immediately informed. Some patients hospitalised without their consent will be provided with an electronic tag which … will automatically set off an alarm.” Sarkozy added, “At least one secure unit will be installed in each establishment which needs it. These units will be equipped with doors and video surveillance systems so that movements may be monitored.”

He called for 200 high security isolation units “for patients who may have fits of violence against staff.” He went further, saying, “Firstly, we are going to set up compulsory treatment in a psychiatric milieu. Eighty percent of your patients are taken care of in the towns. Just as hospitalisation without consent exists, there must be compulsory treatment outside hospital. It’s in the interests of the patient and his family…. We cannot leave on his own a patient who clearly needs treatment and who may refuse to submit to it.”

It is not yet known how far Sarkozy plans to go with obligatory treatment, but the formulation he employs is extremely broad and could potentially embrace all patients under psychiatric care. Such compulsion would constitute a dramatic regression in relation to the rights of patients and to civil liberties in general. Accepted medical ethics place emphasis on obtaining the consent of patients whenever possible.

Sarkozy’s proposals would make more difficult both the temporary and permanent release of patients who are compulsorily hospitalised, and essentially transfer such decisions to the police, with medical staff playing only a consultative role. Were this plan to take effect, cases of arbitrary confinement, with no time limit, would undoubtedly increase.

Mental health facilities would become more like prisons, while already inadequate resources, particularly in the field of outpatient care, would be diverted from health provision to security.

Patrick Chaltiel, a doctor and specialist on violence in psychiatric establishments, has directed the Observatory of Violent Behaviour at Ville-Evrard, one of the largest psychiatric hospitals in France. He commented, “The problem for people suffering from psychological disorders is more their vulnerability than their violence.… Outside the hospital, the mentally ill are 17 times more prone to become victims of aggression than the general public, while their violent behaviour is no greater than that of the general population.” 

Similarly, neuropsychiatrist Boris Cyrulnik, vice-president of the League of Mental Health, stated in an interview on radio France Info, “Statistically, outings accorded in psychiatric hospitals are extremely reliable, there are very, very few accidents. Of course, when there is an accident it’s tragic, it’s spectacular, it’s talked about a lot, but if we prevented people from going out we would not be able to treat anyone.”

Certain violent patients should, of course, be a question of concern. But as Doctor Pierre Muri, president of Saint-Egrève’s medical commission, explained to Libération, “I’m not entirely in agreement when I hear it said that there have never been problems of violent behaviour with schizophrenia patients. I wouldn’t say that. What I know is that well taken care of, there is no problem. But are they well taken care of today?”

In response to this question, the majority of health care professionals would say that more and more frequently mental health patients are badly cared for both in hospital and when back at home. That is why health professionals and patient support organisations are widely opposed to Sarkozy’s plan.