After two months of internship at the Clinique de la Borde, I arrived as an intern-psychologist at the Centre Hospitalier Sainte-Anne, in the 14th arrondissement of Paris. It is one of the four Public Establishments in Mental Health [EPSM] of the capital. A place where once stood the famous, well-divided quarters of the « Agitated », the « Spoiled », etc. In the middle of the 20th century, the anti-psychiatric movements and institutional psychotherapy worked hard to eliminate this style of hospital organization. The Sainte-Anne of 2014 is certainly no longer the Sainte-Anne of Marc Stéphane’s Cité des fous, however, the institution has moved away from the refounding principles of psychiatry for a few decades.
To be in internship at Sainte-Anne after having been in internship at La Borde allows to realize a psychiatric and organizational practice sometimes diametrically opposed. In the unit where I play the budding psychologist, I am a little surprised and even uncomfortable to be in the nurses’ transmission room, separate from the waiting room.
What shocks me is this schism made visible by the obviousness of the architecture between the « psychotic cared-for », sort of Venus de Milo with an amputated psychic body, who patiently wait for the care of the « normotypical caretakers », sort of sculptors in white coats. The metaphor may seem crude, but it is clear that here, patients wait and caregivers care, like the sculptor who carves and the statue that waits to be sculpted with eternal patience.
Here, each patient « benefits » from a program of care, established between the patient himself, his legal guardian or curator if necessary, and the doctor-psychiatrist in charge of the follow-up. The caregivers I have been able to work with have an interesting vision of psychiatry: they do not only aim at the silence of the organs or the annihilation of the symptomatology, but try for the most part to go towards an understanding and a care of the subject. Treating the subject rather than curing the disease. Subtle nuance that could gradually disappear.
What I am questioning here is not the theoretical references, the quality of the training of caregivers, or the motivation of the teams, but rather the institutional clinic, the conception of the collective and the problem of status-role-function. Here, there is no question of a nurse doing the work of an orderly, as his or her tasks may seem less worthy of their qualification. Here, it is with the psychiatrists that we talk during the appointments. Outside of these precise and circumscribed moments, the space-time of language is greatly reduced. At La Borde, the « interstitial clinic » is highly dignified: we work on the atmosphere, the relationships, the existence. In my unit at Sainte-Anne, the « in-between clinic » is little valued, not worked on and is only a time of waiting between two things, so to speak a useless time. In a five-minute walk with a Laboratoires resident, I sometimes learned more than in a forty-five minute interview with a St. Anne’s patient. Here, the patient is perceived mainly in his or her individuality, in his or her relationships with his or her family, work, etc. The relationship with other patients seems to be of little interest to the caregivers, who do not seem to give credit to the analysis of the patient’s relationship with the group. This is perhaps because here the patients form a « bunch of people » as Oury describes it, unlike at La Borde where the aim is the permanent and plastic formation of a collective.
Is La Borde a possible and relevant alternative model for psychiatry? Some unwise detractors might answer that the Laboratoires model cannot be duplicated because it is too expensive, with a discourse similar to « It’s normal that La Borde works well, it’s a private clinic, with a castle, a lot of outbuildings, horses, a huge vegetable garden, parties all the time. They have money for sure ». To this, let’s answer very prosaically that the price of a day at la Borde is on average six times less expensive than a classic EPSM, which gives for example 120€ per day and per patient for la Borde against about 800€ per day and per patient for Sainte-Anne. And yet la Borde is constantly in the grip of the risk of closure, notably because of the increasingly important requirements of the High Authority of Health, whereas from an economic, ethical and care point of view, la Borde still remains an exciting alternative model of psychological care and societal mutation.