Louis

 

The following mails constitute the various attempts of intervention in favour of a patient to the different levels of the administrative hierarchy, from the bottom to the top. They testify of the passivity of the persons in charge of this administration in front of the abuses which occur in it when it is informed on them, and of the impossibility for a individual alone, to conform himself to the rules of deontology to which he is hold, the respect of professional secrecy being then incompatible with the interest of the patients whom he is responsible for. 

Letter of June 21, 1989 with the chief-supervisor of sector IV:

Dear Michel,

 A little more than one week ago, under the influence of an auditive hallucination, in the unit A. where he is hospitalized, Louis P. strikes two patients whom he hears threatenning him. In prey to a deep anxiety, he is unable to take distance towards his hallucinations. It is decided that consequently, he will remain three days in insulation room. The third day, Louis learns that he will have to remain isolated two more days . He did not commit any reprehensible action justifying this decision. If one believes the book of report, the reason which is given to him is that it is not " not of a punishment but about a help ". From our conversation of yesterday I deduce that he was not released yet at the end of seven days.

Since two years, Louis has been charged charge in 1987 a kick to Irene Irene, always following a hallucination, then he ha been sent eleven month to Cadillac. In 1988, during a crisis of anxiety, he gave a kick to Dominique and some days later, he broke a pile of plates in T. After several days of insulation, he was sent to Cadillac for eight month. During the two years (24 months), it will thus have spent 19 month in detention in a prison hospital, more about a month in insulation at T, which gives: 3 kicks + 1 blow of fist = 20 months of enfermement.

 Louis has been hospitalized for eleven years in T. At his arrival, he was a slender, alive boy and in good physical health. Today he weighs more than 100 kilos, suffers from hypertension and drinks about fifteen liters of water per day.

 During all these years, X (husband of the nurse) and I saw him evolving, inside as outside the hospital. Since the first times, X had with him regular talks; we made with him several stays outside; during this time his symptoms (return to itself, hallucinations, etc.) regressed. It was then active, relaxed, not-aggressive and respectful of the fixed limits and of other people; he was taking distance towards his hospitalization, was becoming aware of its duration. At the little school (group B 23 ) which he was one of the main members of, and through the magazine "Objectifs " to which he took part actively (articles, printing, etc), he was always volunteer for the activities which were proposed to him as well as attentive and goodwilling in what he was doing. He has showed that, under favorable conditions, he was able to be pleasant to relate to. He obviously has a good souvenirs of it since he keeps asking us to take him out along in new excursions.

Louis requires from us a coherent attitude: how many times did I hear him asking : " But tell me what I have to do to leave this hospital. "

" To get up in the morning, to take a bath, to manage correctly with your money and your cigarettes, to take part in the domestic tasks and the workshops. " During several months, he made the effort to make correctly the work which was expected from him, hoping to see an evolution of his situation. Then, as the months passed, he did not notice any recognition of his efforts and did not see any hope to go out , and then he fell again into his inertia. The fact is that when Louis is aggressive, he sets off effervescence, but when he is calm, he tends to be relegated to the oubliettes.

  He takes more and more as a refuge his memories before his hospitalization, trying desperately to join again friends from the Seventies (the time he lived in Nice-Marseilles , of his trips abroad). His delirious remarks testify of an increasing anxiety (fear of " facists ", people who make him "freak out"... ).

" The psychosis would just be the result of a memorized organization of anxiety and some escape in the imaginary because of impossibility to find a solution in the action... Why is there regression? One can think that the imaginary, which cannot enrich itself only starting from one new memorized hardware, the separation, the progressive insulation from the world prohibit all new contribution starting from the environment. " Henri Laborit

If one considers his delirium like an escape in the imaginary, (the only one which is possible to him) towards a reality which is unbearable to him (place of enfermement with blurred limit , without any prospect of future, which sends back to him the image of himself of a mental patient who scares people), an appropriate way to fight his delirium and his anxiety pass ineluctably by a exploitation of his capacity and cares adapted to his needs. It's our job to fulfill his needs the best we can and not his job to act according to our desires (or our lack of desire ). Ignoring his desires and deciding without consulting him of activity that one imposes to him then (it is the step which was advised during the last meeting with the staff of watch nurses) is, to my humble opinion, infantilizing, not realistic according to the therapeutic optics, and a complete lack of the respect we as nuses, must have towards him .

To attribute an exacerbation of his delirium and of his anxiety only to his pathology and to answer his crisis by an insulation of several day while he remains locked up in his room with, as only interlocutor , his tape recorder, five tapes, cigarettes and a toilet bucket, seems to me unsuitable for the following reasons :

 - this insulation can just reinforce his delirious and his anguish as well as the image of persecutors he has of some nurses; 

- his delirium and anxiety are symptoms. One can present to him his enfermement " not like a punishment but like a help ", this does not lower his suffering. Moreover, Louis is not stupid. He knows very well that insulation is one of the usual punishments in the service. However a punishment implies a fault and a fault implicate guilt. However Louis is neither guilty to be delirious nor guilty to feel prosecuted; he is the first one to suffer from it. And to consider his situation under the angle of a problematic of culpability is more a neurotic reaction than a healthy one.

 - to consider his behavior independently of his surrounding is an unsuitable vision based upon an obsolete wy of thinking. Each person is a psychosomatic whole in his surrounding which penetrates him and to which he reacts; to separate on one side the body, on another one the psychism and to make abstraction of the surrounding is an elementalist step which isolates artificially elements and factors which are structurally bound to each other.

 - to invoke chronicity to do nothing , pretexting that it is too late, it a position of looser. It neglects the fact that, like all human beings, Louis is in constant evolution. To consider his disease as a definitive handicap fixed once for all is an obsolete static vision not corresponding to reality. This sends back to Louis a desperate image of himself and shows a reducing optic of our nurse job . Finally, the argument of chronicity appears to me as a practical excuse, but not a very glorious one for nurses to escape their responsabilities towards the patients.

Another point: in Cadillac, Louis was mingled with more violent people than him , half of whom committed criminal aggressions (see Libération of May 31st 1989). How can we be surprised that when he comes back, he got a violent speach ? The opposite would be astonishing. Moreover, such frequentation can only reinforce him in the image of delinquent he had of himself in the past.

Last point, Louis does not have, by far , the monopole for distributing kicks in the institution. Other people, like Georges or Robert, distribute theirs with a strength and a frequency which, if one make the account, exceed a lot Louis' ones . However his aggressive remark or acts take immediately a dramatic aspect with the staff, whereas those of the others seem to be considered as part of the disadvantages inherent to the institution.

My intention is not to minimize Louis' acts . I know, for having received my share of hits, that it is far from being pleasant. I have lived a similar situation myself to the one of my colleague when I was working in the service G, from Robert D. , without the staff of this service being moved the least of world and I know how such a situation can be scarry. I believe that it is important to consider things with a less dramatic look about what's going on today , as well as to work seriously to help Louis to restructurate again , both works being bound.. I also believe that we must be honest with ourselves: to see Louis locked up reassures the staff, this appears as obvious to me. But to claim that he is locked up to reassure him is , to me , a sophism according to the rules of the art ! Try thus to isolate yourself one week under the same conditions and you will give me a feed-back then !

Moreover at the penal level, measures of insulation are reserved in France to terrorists. Hardly bearable, they are part of the " degrading treatments " punishable by the Council of Europe since France has ratified , on June the 25 1987, the " European Convention for the prevention of torture and of sorrow or inhuman and degrading treatments ". (see Liberation of June 25th 1987)

 The present politic at the national level aims to an improvement of the rights of the patients. The senate has just modified the article 64 by abandonning the concept of irresponsibility to the profit of the one of " non-punishability ": "There is no crime nor offence when the accused is in state of insanity at the time of action or when he has been constrained by a force to which he c could not resist. " (see Liberation of May 31st 1989). What Francis Jeanson said at the recent conference of psychiatry concerning the enfermement of patients and ethics seems to me particularly adapted here and worth being meditated.

 On the practical plan, here are some proposals likely to make the situation progress :

 

1) At the level of Louis' cares :

If one adapts a therapeutic to the needs of the patients and one allows them to be active in their cares, one generally states an improvement of their condition; example: the little school (groupe B 23). There is no mystery here: " truth is verifiable ". Pr. Jean Bernard.

a. To define his fundamental needs

b. To draw up a list of his known aptitudes:

 - he can type with the machine,

 - he takes part to manual activities,

 - he is able to write articles for a newspaper,

 - he likes to play theatre,

 - he speaks English ,

 - he is interested in the music,

 - he took part to the printing of the magazine,

 - etc.

c. What can the institution bring to him?

 - to make him work intellectually,

 - to make him take part of a show (theatre, video, etc.)

 - to make him type with the type-writting, teach him how to use a computor,

 - to encourage him to read, to write,

 - to make him have physical activities: outputs bicycle, gymnastics, etc.

 - to help him to learn how to reason logically: exercises of logic, training of general semantics, etc.

 - to take him outside: cinema, House for All, walks with other people, etc.

 - to settle with him a healthy relationship based upon the respect of himself and the others,

 - etc.

 This would involve on the level of its organization the following modifications:

 - possibility of acting, hence a fall of inhibition of the action, a fall of the anxiety;

at the chemical level: lowering of cortisol and néosynéphrine, from where a fall of its hypertension and an increase in his immunizing defenses,

 - acquisition of new information, hence opening of new synaptic ways, hence increase in the use of his capacities on the level of the nervous system,

 - revalorization, hence an improvement of the image of himself and others: in terms of transactional analysis, to transform his position from NOK-NOK into OK-OK, hence an improvement of the team work.

 - improvement of his physical condition.

Here are some examples, easily organizable and with few expenses.

Béthéleim: " What we are initially looking for , it is to give our patients a livable life. That is done by the institution in its totality , then only one member of the staff can go beyond and help the patients to like life, to enjoy life. And there is a big difference between finding the life livable and enjoying life. Because this is what being cured means. "

 Instead of answering his is delirium and his anxiety by enfermement, let us start by giving him a livable life.

  

2) At the level of the staff :

 - to allow the people to talk about what the frear their fear and to think altogether why it takes such proportions,

- how to react effectively and positively in front of anxiety, delirium it and the fear of the patients, role of these elements in their violent behavior,

 - self-respect and respect of the others, respect of the nurses and respect of the patients,

 - etc.

 Conclusion:

 I am writing this letter to you because I need to exchange with the people I work with about my interrogations and my reflexions concerning my job. Our job, whatever our function in the institution may be , is difficult and sometimes distressing. This aspect is undoubtedly related to the high number of deaths among the staff during these ten last years (8 since 1980).

 We have the choice between working together in a cordial relational climate of mutual respect by mobilizing our human resources for a greater comfort of the patients, or privileging our interests and search of personnel dominancy in a conflictual environment in contempt of our function, of the patients and public services which we belong to.

 You have a significant role in the service, a position of link between the various units. I do not believe to mislead me by thinking if you are a chief - supervisor today, it is due to the qualities of integrity, humanity and serious you showed before, this is why the this letter is also a proof of trust.

 Instead of polarizing on the negative aspects of Louis and to see him only as one calamity, let us consider him as a chance. He can represent for us the occasion to realize a true therapeutic work together.

 Sincerely.

 

Openned letter to the nurses of the sector IV: June 12, 1990

I chose today to write to you to tell you about the present situation of Louis P., situation which, in my view, deserves reflexion and analyzes.

I privileged the use of writing because it seems more favourable to me to give an account of this analysis than the oral expression.

I based this reflexion and this analysis on a certain number of facts and it appeared significant to me to express this to you, because the conscience that I have of it is presently not any more bearable to me neither professionally nor humanly .

 I Summary of the recent facts:

 On May 15th, 1990, Louis P. strikes Monique L and Stéphane C. Following that, it is locked up the very same day in the cell room at the first stage. He remains there until May 21, i.e. six days, then goes back to the service V where he remains locked up in his room until May 28, if I believe the book of reports . His gesture of aggressiveness will thus have led for him to 13 days of enfermement .

 On May 23rd, a request for a transfer for the U.M.D. (Unite pour Malades Difficile : Unit for Difficul Patients) Cadillac is carried out " in the event of need ". When Louis came back to the service it was no more question of Cadillac until June the 6th ; at this date the book of report mentions a " project of stay in Cadillac ". The following day, still in the book of report, is announce the decision of " next departure of Louis to Cadillac ", without him having committed, to my knowledge, any violence likely to justify this decision nor to constitute the " need " mentioned at the time of the request carried out on May the 23rd , the only new element in the book of report being the agreement of DASS (Direction Departementale de l'Action Sanitaire et Sociale ) of the Gironde for the transfer of Louis.

 

II What the U.M.D. of Cadillac?

  " The units for difficult patients are special places. In these closed wards , functioning like real prisons - with gates, keys and omnipresent rules - one gathers the patients supposed to be the most dangerous or the most aggressive patients. " Release, 8.11.89

 " Half of the patients committed criminal aggressions... All the patients are placed under the mode of placement of office. " We are the last link of the chain. You cannot find lower. One gets rid on our premises of those which one does not know what to do with somewhere else. " (Doctor Gaussarès).

 " Aggressiveness is not supported any more in the services of traditional psychiatry. As soon as there is a problem, as soon as a patient becomes disturbing, I can ensure you that he will land in a U.M.D. " (the psychologist of Cadillac.)

 " THE U.M.D. knows this well. Everyone outside prefers to ignore its existence, delighted by be removed from these " cases " judged unresolved. " Release, 31.5.89

  

III Arguments pretexted to justify the transfer:

  1) " Louis requires it ": personally, I never heard Louis speak about Cadillac as of a place where he wishes to live, but rather as of a place where he fears to go: " He will not go back any more to Cadillac, Louis? No ! " he adds to reassure himself. His evocation of the memories that it got is often sinister, except for his relation with the doctor, Mrs Ferré. I asked him whether he wished to go back there. Answer: " No, that does not interest me. "

 2) " A stay for a rupture ": Cadillac is not properly speaking the place of predilection for such stays of rupture; it is a prison. Moreover the other patients are not sent there for such stays : they go in places more cheering and openned places.

 3) " By coherence with respect to Cadillac ": I do not know on which criteria of evaluation can rest this " coherence with respect to Cadillac ". I acknowledge that it exceeds my capacities of understanding. I do not see where coherence resides when the speeches held to Louis are contradictory and they do not correspond to the reality of the decisions which are imposed to him. As nurses, we have to be coherent towards Louis first , as his wellbeing is the most important in the circumstance.

  

IV Comparison between Louis P. and George D.:

   One can easily note with the gleam of the facts that if Louis is the most sanctioned patient, he arrives bay far behind of others in the prize list of the violence and the frequency of the acts. Thus George D., since his arrival with the service of X, saw himself charged for the following acts:

 entered on September 25 89,

 - on October 20, he breaks the nose of Marie,

 - on October 30, he slaps Karine,

 - on October 31, he thrashes Philippe A.,

 - on November 3: blow to Rene P.,

 - on December 15: slaps to Karine,

 - on December 28: hits Jean-Marie and Jean-Marc,

 - on January 16 90: hits Marie on several occasions,

 - on January 26: hits Mr. B in the service V,

 - on February 2: hits Mr. B again,

 - on February 11: break a brush on Louis'back

 - on February 15: hits Anne-Marie,

 - on March 31: brawls with Stéphane,

 - on April 8: hits Jean-Marie; intervention of 7 male nurses; hits Anne-Marie and Laurent; hospitalized in the service V during one week,

 - on May 6: hits Domenica V and breaks his glasses .

  

Are not included in this list its former violences (broken coasts to Mr. M, blows to Anita B, kicks in the belly to Marie-Claude D., etc.)

 One can then observe that George struck more people during 8 months than Louis in twelve years of hospitalization. Paradoxically, though George is neither delirious, nor stupid and that he is able to evaluate the consequences of his acts, nobody asks for him to be put in placement of office, nor sent to Cadillac, nor even of infermement room . His aggressions " are generally seen with him during talks "; the most severe sanction which he got was one week of hospitalization at the service V, service within the framework of which he was free to come and go .

 On the occupational level, George is part of many activities inside as outside the hospital (at T, cinema, training course C.A.T. ) (C.A.T. : centre d'aide par le travail : entreprises which emply handicaped people). He goes regularly to see his family and sees his requests and desires taken into account by the staff. His conditions of hospitalization are of much more enviables than those of the majority of his fellows.

 In comparison those of Louis are infinitely more precarious:

 In June 89, when he had been transferred from the service C to the service V, he had been told that he was coming there " for three weeks ". He is still here, a year later without any project being worked out for him at the level of his care. He also is always anxious and delirious and the hypertension from which he suffered already has increased.

 When he arrived at the hospital twelve years ago, he was living in his family and had a job. During all those years, no serious attempt to take him outside was considered for him, unless a short passage to the therapeutic flat where he was alone most of the time except when he was coming to the hospital during the day , passage which was a failure. Since he was put un, then in placement of office the 7.5.87, P.O. which was never supressed since. Before being sent to Cadillac, he was going regularly to spend the weekends in its family. These permissions were removed. Before the putting up of the " new structure " (1987), he was taking part in activities in the Social Center, the small school, the magazine " Objectifs " and stays out of the hospital. Except a few episodical days to T, he has remained confined for one year inside the service, with for only occupations the housework and the retranscription of his interior speech on exercise- books. He often asks to be taken out for comping stays, but the current organization of the service V does not authorize any more these activities. For several months, we have asked the superviser to be able to take out a group of patients to their request, in vain. A few months ago, Louis had asked to go and visit Mr. M., in the old people's home, accompanied by the male nurse of sector who visits him regularly, his request was rejected. He would also wish to make activities of gardening: no the answer. He is stripped of any consultation and decision-making power concerning his life. He often asks how long he will be hospitalized, if he will stay here during his whole life . His fright of death is increasingly present and do not seem without relation with his conditions of hospitalization and the degradation of his health. He has no regular talk with a doctor, being seen only when he expresses his anguish too much. My colleagues who work during the day deplore the impossibility in which they are to undertake with him a real therapeutic work and say that the episodical presence of the personnel present between 9 hours and 17 hours does not allow the organization of activities real therapeutic aims.   

 In the pages that I have addressed the last year to Mr. L (supervisor-chief), I propose a certain number of simple measures the aim of which was, at the level of Louis, to fulfill his needs and, at the level of the staff, to undertake a start of thinking on the situations of aggressiveness and on our work of nurses. Nothing was undertaken since that time to improve the cares of Louis nor to give the staff the ways to begin a real therapeutic work . The only answers to the crises and demonstrations of anguish of Louis are limited to administrations of sedative pills and insulation.

 I wonder about the reasons of such a difference in cares between patients and on which logic it rests .

 It seems that one attends a confusion between the level of the words and the level of the acts; example: the violences of George are expressed on the level of the acts, of the facts, i.e. to the detriment of people who undergo them physically. Louis is generally aggressive on the level of the words: the threats that he utters against various people, (among which we are X and me), remain on the level of the speech and do not concretize themselves in reality. They then do not harm anybody. They remain on the level of his delirium and, at this stage, the person who suffers from it is Louis himself. When he threatens me in words, it is because he saw me in his delirium las one of his persecutors, but that does not do any harm to me. In reality, I often go towards him, he comes towards me and knows that he can speak to me because I will listen to him; he never did any harm to me.

 His words can lead to reactions of fear, but as long as the words to dot concretize at the level of act, this fear, if it is comprehensible, is not obligatorily justified . There is then easy means to dissipate it: talking to him about it, relating to him on a non guilty way, dedramatize , which destroys Louis' fear and the fear that one feels. That also allows to fix to him the limits he needs and to start on new , healthier bases. On the other hand, if the fear which one tests in front of his delirium involves from us a reaction of a repressive nature, on the one hand that reveals our impotence to act at the therapeutic level and on the other hand it means that one penalizes his delirium and that one considers that he is in a certain way guilty to be sick. One obeys then a logic based on the concept of victimless crime.

 To conclude this analysis, I make a point of releasing my responsibility concerning the conditions for hospitalization of Louis P. and his transfer to Cadillac. As nurses, we are confronted to the diseases of the patients, to their suffering, and our role consists in relieving them as much as we can, not to reinforce the reject from which they suffer nor to make them become excluded among the excluded. This is why this situation does not seem to me cautionnable at the professional level.

 It does not appear either cautionnable to me at the human level: " To be man, said Saint-Exupéry, it is to be responsible. " And if today we escape our responsibilities by abandonning Louis to his sad fate, on the assumption that we might find ourselves one day in a comparable situation because of the chances of the life, we could then hardly expect from others what we were not able to expect from ourselves.

 Briefly, this situation appears to me as incompatible with the concepts of self-respect and respect of the others, and the ethical and humanistic values which are required from us as members of public health.

 Hoping that this letter will allow to start a common reflexion and a real therapeutic work around Louis P., I join a copy of the letter sent last year to Mr. L and you ask to believe in the insurance of my sincere greeting.

  

Letter of August 10, 1990 to the President of the Republic François Mitterrand:

 

Mr. President,

 I work as a nurse of psychiatric sector at the hospital of T in the department X, hospital in which I was trained and where I work since obtaining my diploma in December 1978.

 I have decided to write to you today and to open the structure of the hospital at the informational level to attract your attention on the case of a patient, Louis X, 36 years old, and hospitalized since twelve years in the sector where I work, his condition of hospitalization appearing to me as not compatible neither with the Constitution of our country which guarantees each citizen, even mental patients, natural and inalienable rights, nor with the respect due to patients from public health, nor with the therapeutic consideration supposed to be at the base of our work of nurses.

  Louis P. was led on July 6, 1990 to the C.H.S. of Cadillac sur Garonne, in a Unit for Difficult Patients, for the third time of his existence. Sent in 1987 to this hospital in theory for one month following a kick which he had given to a nurse, he has in fact remained there eleven months. He returned there during eight month in 1988, following an anxious episode at the time durrintg which he had struck another nurse and had broken a pile of plates. The first two transfers had been presented to him like disciplinary measurements. This last one is supposed to be " not punishment but of stay of rupture ". Actually, it follows upon a request for transfer carried out on 23 May 1990, after he had struck two others hospitalized patients and had been, following that, locked up during thirteen days, initially in the insulation room, then in a normal room.

Mr P. is in placement of office since May 7, 1987, P.O. which was never supressed since. At his arrival at the hospital here twelve years ago, he was a boy in good physical health, intelligent, of a satisfactory intellectual and cultural level. Before he was put in P.O., he was taking part regularly to walks and stays outside. During the years 1984, 85 and 86, he was one of the main elements of the group B 23, a school with educational vocation that my husband, also nurse, and me had set up with a group of nurses and patients. He also took part with assiduity to the work magazine of the group, " Objectifs ". He never posed the least problem in this context; on the contrary he was appreciated by the other members of the group by his humour, his goodwill and hi capacities . His first transfer in 1987 coincided with the interruption of the group B 23, following a reorganization of the service which had made its continuation impossible

The group was considered by a certain number of persons in charge of the service as " too educational, not psychiatric enough ", and the nurses who animated them were reproached, amongst other things, for being " on the patients' side".

Since 1987, the only image which is returned to Louis P. from himself is the one, negative and despising , of a delirious mental patient, incomprehensible and dangerous. His potential, his positive aspects, are ignored; he often gets devaluing, inhibiting remarks , which lead him to take refuge in his delirium, which is the only way out which remains to him to escape an unbearable reality. His hospitalization under these conditions, far from helping him to get rid of the disease, contributes to maintian him in it. The duration of the enfermements which he undergoes is disproportionate with the acts which are reproached to him and not compairable with the sanctions he would have got if, considered as responsible for his acts, he had been condemned by a court for the same facts.

During his last stay in Cadillac, the report of the doctor there shows that, during eight months, he showed no aggressiveness, including towards others hospitalized of the U.M.D. from whom he underwent aggressiveness, not being able to defend himself.

At the physical level, his health has degraded gradually, especially since he is in P.O.: the lack of exercises, the forced inaction, the daily absorption of significant amounts of sedative pills, resulted in a strong catch of weight and a high hypertension.

Today, too cut from reality to undertake the steps which would enable him to influence his situation, he has not got any support outside, unless his mother, who is ill and old. Under these conditions, he can only undergo what happens to him. He has also sisters but they rarely see him and miss elements to ensure his defense.

As far as I am concerned, I have tried various steps at the level of the hospital, writting amongst other things by letter last year to my chief- supervisor and recently to the whole staff of nurses, to allow a comune analysis and reflexion on the events and to lead to better cares for his needs , in vain. My letter of last year having led to no reaction, I transmitted it to the director of the establishment, step which was considered thereafter as " insulting ". The one I wrote this year, which was welcome by my nurses colleagues, was properly eluded by the higher levels.

Unfortunately, Louis P. is not the first patient to see himself confronted to conditions of total emergency in the service: in 1983, Mr Gustave L died at 94 y. o. after a hunger strike which he had undertaken to protest against his internment in voluntary placement after he had accused the director of the old people's home where he was living for stealing his money, charges which appeared exact after his death. In 1987, Theophane O. was physically agressed several times by another patient, without anybody cared about it. In the first case I realized what had occurred only after Mr L. died . In the case of Mr O, I could contact the Director of the establishment who could put an end to these aggressions. Today, concerning Mr P., I tried all the ways I could, in vain and I do not have any more possibility of action inside the hospital. The only thing that I can make is to carry information out of the walls. And I must make it, otherwise I warrant these events and I accept the possibility that other hospitalized people might in future continue to bear unbearable things. Because of their handicap, patients in psychiatry are seldom able to become aware of the abuses which they undergo and even less to dispute them, as they are impregnated with the feeling of their unworthiness, because of shame and of rejection which weighs on the sphere of mental illness. Victims of a pedagogy of the culpability, they must undergo their fate in acceptance. On the assumption that they would not accept it, their statute of mental patient is enough to disqualify their word and to justify what they undergo.

What characterizes mental illness, beyond any nosographic classification, is mental anguish. There are services where the purpose of the work of the whole staff is to relieve this suffering. The term of healers, applied to the members of these staff, is then fully justified. But in other services the real goal, in spite of appearance and of speeches, consists in preserving at all costs the structures and, in the name of " the dynamic activity of the services ", to maintain the patients within the framework of these structure, pretexting the postulate of incurability of mental illness, even if the price to pay is dependence, degradation and death of human being. The suffering, then due to the disease, is standardized and, because of inertia and routine, ends up to be part part of the daily life. The words of " therapeutic ", of " care ", in the name of which these structures are perennialized, are emptied of their meaning. The simple reference to the law is considered as subversive, and the evocation of ethics, as demagogic. Then nothing is true any more there and everything becomes permitted as far as alienation is concerned.

As a nurse, I was trained and I am paid to lead the patients to a state of better being and of autonomy, if I believe the text relating to the exercise of the profession of nurse : DGS/DH N387 of September 15, 1989 , that Mister the Minister Claude Evin forwarded to my colleagues and myself.

Insofar as it is your government which defines my function and which remunerates me, it appeared to to me that in despair of cause it was of my duty to ask for your advice.

I am enclosing in this letter several elements which will enable you to evaluate the grounds of my assertions, namely:

- a copy of the letters addressed to my chief-supervisor and to the whole staff concerning Louis X,

- two issues of the magazine Objectifs which shows the work of the group B 23,

- two chapters of a book of which I undertook the drafting, one on Mr L (" Mr Agnelet ") and the other on Mr O (" Modeste "). In both cases I included the elements of data coming from their file and the books of report, elements where my point of view does not interfere and on the basis of which the observer is able to forge his own opinion,

- an account of a recent institutional meeting (May 28, 1990) realized by a trainee supervisor, report which illustrates the current relational problems.

Mr. President, hoping this letter will allow an improvement of Louis P.'s life , I recommend to your attention the fate of this boy. I am, of course fully at your disposal to provide you all the other elements which you might require.

Allow me to ensure you, Mr. President, of my respectful greetings, my sharp regard and my sincere devotion.

Answers:

PRESIDENCY OF the REPUBLIC, Paris, August 22, 1990

Reference to be recalled: SC/3/C70347

 

Madam,

I was charged to reply to the letter which you addressed on to August 10, 1990 to Mr. President of the Republic. I thank you for having agreed to announce your reflexion to the head of the state. Be assured that it was taken good note of your remarks of which I informed at once the Minister of solidarity, health and social protection more particularly qualified to examine them. Sincerely yours

X charged of Mission

 

MINISTRY OF the SOLIDARITY OF HEALTH AND SOCIAL PROTECTION : October 1, 1990

 

Cabinet of the Minister

REFERENCE DH

 ATTENTION the reference and the date of this letter are to be recalled for any information.

Madam,

Mr Claude EVIN, Minister for solidarity, health and social protection, received your correspondence transmitted by the Presidency of the Republic which is the subject of an attentive examination in his services.

 

As soon as possible you will be informed of the continuation that it is likely to receive.

Sincerely yours

The principal Attache,

YY

Chapters in English: Introduction , Mr Agnelet , Mr B , Louis , Declaration of the Human Rights of Citizen - 1789

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