With a megaphone in one hand and leaflets in the other, Isabelle Bouligaud walks back and forth in front of a crowd of nurses and healthcare assistants stretched out on the road in Saint-Etienne, in central France. One by one, she reels off the ills plaguing her profession: the shortages of staff, hospital places and resources. Psychiatric care, once the pride of France, as mirrored by this ‘die-in’, now finds itself decimated.
“I feel like I’m no longer doing the work I’m paid for and just making a pretence of treating patients,” says 44-year-old Bouligaud, who has spent 21 years in the mental health care sector. This child psychiatric nurse, who is also the Force Ouvrière (FO) union representative at the University Hospital Centre (CHU) in Saint-Etienne, says that her work has been stripped of its meaning over the years. “For the past two years, I have been working with a 12-year-old boy with relational problems. I was seeing him every week, and we’ve been able to work on his behaviour and his anxieties. But I haven’t seen him since September, because of the staff shortages and reorganisations. It’s a bit like taking someone’s cast off too soon. It creates frustration, because we are not able to do our jobs properly.”
The demonstrators say they are not there to “get a pay rise”. It is the quality of the care that is the focus of their concern. It was, precisely, the quality of the care that was firmly called into question by the visit, in January, of Adeline Hazan, Controller-General of the CGLPL, the independent public authority in charge of ensuring respect for the fundamental rights of persons deprived of their freedom.
Her findings pointed to “inhumane and degrading treatment”, citing cases of mental health patients who had been unjustifiably tied up or left waiting in the general emergency department for several days and “had not been able to wash, change, or have access to their mobile phones”.
One patient had been locked in an isolation room for several months – well in excess of the regulatory limit. In 2017, the French Health Authority (HAS) advised that “a patient at risk of being a danger to himself or others should not be locked up for more than 12 hours and not restrained for more than six”, and that restraint, as with isolation, should only be used as a last resort and as a temporary measure.
In a press release responding to the “illegal and abusive” practices highlighted by the CGLPL, the management of the Saint-Etienne University Hospital pointed to staffing and hospital bed shortages. “The number of patients increased by 30 per cent between 2012 and 2016, partly as a result of the limited number of private psychiatrists.”
The departments concerned were deeply shaken up by the report. “It acted as a detonator. I, personally, was relieved that it was published. I thought, at last, we’re going to be able to make things happen,” says Nicolas Moulin, a night nurse and CGT staff representative. Bouligaud expands on her colleague’s view: “Others felt guilty, they realised that they had restricted patients’ freedom without really thinking that it was against the law. It came as a shock.” The sense of outrage drove the staff to rally under the banner of ‘La Psy cause’, a collective voicing their demands and coordinating strike calls and actions.
Restraint, the symptom of ailing mental health care
The Saint-Etienne University Hospital is by no means the only institution where recourse to restraint and isolation has been abused. In 2016, Hazan had already denounced the“increasingly widespread use of restraint and isolation” (patients kept in isolation, attached to their beds, sedated) in at least 40 per cent of France’s mental health institutions. For specialists in the field, the findings are indicative of the overall state of the mental health care system. “Recourse to restraint is a measure of whether the mental health sector is in good or poor health. The worse it gets, the more it resort to restraint,” said Dr Jean-Claude Pénochet, former president of hospital psychiatrists’ union SPH, during a parliamentary inquiry in 2013.
The increasing use of restraint to manage patients is the most indicative sign, but beyond that, all the warning lights are red. This is the conclusion drawn by psychiatrists Marion Leboyer and Pierre-Michel Llorca in their book Psychiatrie, l’état d’urgence (Psychiatry, a State of Emergency), published in September 2018. In it, they denounce “a deafening silence that is ongoing and speaks volumes about the perception of psychiatry in [the] country, which lies at the junction between ignorance, misconception, prejudice, denial and shame”.
They point to diagnostic delays of several years, with patients waiting several months for an appointment with a psychiatrist, whilst one French person in five is reportedly affected by a mental health condition requiring treatment: such as depression, schizophrenia, autism, eating disorders and suicidal behaviour, etc.
To protest against the loss of meaning in their work, mental health professionals have been protesting for several months, all across France. In Rouen, eight of them even went on an 18-day hunger strike. Anne Aubrun, a day nurse at a hospital in Rouen, tells Equal Times: “The situation was untenable and we wanted to strike a blow: because of the lack of beds, teenagers were admitted to adult wards and there were cases of sexual assault.” They finally obtained a promise of staff increases, although these fell short of their demands.
Part of the problem also lies in the shortage of practitioners in public hospitals. “In my department alone, two young doctors have just left the hospital to go private,” sighs the nurse. According to hospital psychiatrists’ union SPH, 2,525 mental health care jobs are either vacant or occupied by non-permanent staff.
While staffing levels are falling, patient numbers are constantly on the rise: between 1991 and 2003, they increased by 62 per cent for general psychiatry, with an annual increase of three to five per cent. It can take patients years to get an appointment. These same delays would be inconceivable and unacceptable in an oncology department.
The “poor relative” of the health system
Mental health staff shortages combined with the lack of beds is an explosive brew. In August of this year, the occupancy rate at the Rouvray hospital was still 107 per cent. Aubrun explains: “We were accommodating patients on camp beds, wherever we could, in medical offices, visiting rooms, without access to sanitary facilities, to the point that we were doubling or tripling the rooms.”
To understand the current overcrowding in France’s psychiatric hospitals, we have to look back to the 1960s and the birth of modern French psychiatry. The new system emerged out of a tragedy: during the Second World War, between 1940 and 1945, 45,000 patients died of hunger, forgotten in the overpopulated French asylums under the Vichy regime.
Opposed to the ‘confinement of lunatics’, the post-war healthcare system opted to ‘deinstitutionalise’ mental health care and to treat patients outside the hospital environment. “The duty of psychiatrists is to go to the people,” explained Dr Lucien Bonafé in 1975. Various structures were then set up: day care centres, part-time care centres, spas, therapeutic apartments, etc. The aim was to reduce the need for full hospitalisation, which was costly and stigmatised the patient. The number of beds was reduced over the years, from 120,000 to 55,000 between 1990 and 2011. But the problem has not been solved.
“As many of these centres have closed, or the waiting lists are too long, patients turn to the hospitals, even though they do not belong here,” explains Aubrun.
Marion Leboyer and Pierre-Michel Llorca also advocate fighting against stigmatisation. For mental health professionals, the lack of resources reflects a long-standing indifference on the part of the public authorities to the suffering of the patients, and the staff. Health Minister Agnes Buzyn has acknowledged that psychiatry is indeed the “poor relative” of the health care system. All were hoping that measures dedicated to mental health care would be included in the Health Reform that was announced just a month ago.