Livia Velpry

The Patient’s View: Issues of Theory and Practice

Almost all the knowledge now produced about psychiatry includes what is called “the patient’s or client’s perspective.” This paper analyzes how this notion has been framed in the discourses on mental health over the last two decades, particularly in mental health research and in anthropology. The very concept of the “patient’s perspective” is a social and historical construct. Despite its remarkable prevalence, the notion remains vague. Mental health research pictures it as a stable attribute of the individual. Anthropologists integrate the contextual nature of the patient view; but they still largely envision the psychiatric patient as a rational actor producing narratives based on common sense. However, in psychiatric practice, the client’s perspective is not something the patient individually produces; it is rather shaped by and in a context. To explore this process, my research investigated interactions between staff and patients in a French community mental health center, and showed that the client’s perspective is the result of a collective process. Further analysis demonstrates that eliciting or producing the patient’s view is sometimes considered a therapeutic goal in itself, since being granted the status of a rational and narrative actor gives access to the most valued model of care, one that is based on partnership. Being an outcome that is negotiated between patients and care providers, the “patient’s view” then becomes a new resource in mental health settings.

La violence envers les personnes atteintes de troubles mentaux : revue de la littérature et des notions connexes

BACKGROUND People with severe mental disorders tend to be seen as authors rather than as victims of violence, while mental illness is associated with violence and danger. French policy focuses on individuals with mental illness as authors of violence, to the detriment of evidence-based public health regarding such individuals when they are victims. METHODS This article reviews knowledge concerning violence towards people with severe psychiatric disorders, clarifies what is meant by violence and raises the question of the need for local and national studies. The first part compares definitions and operationalisation of main variables, sampling, methods and results of studies published since 1990 on violence towards adults with severe psychiatric disorders. The second part draws on qualitative studies to clarify conceptual problems that arose in the review. RESULTS Rates of victimisation for individuals with severe psychiatric disorders are shown to be high and far greater than those for the general population, despite the heterogeneity of studies in terms of sample characteristics, measures, methods and analyses. Certain types of factors - clinical, treatment, contextual - raise the probability of becoming a victim, as does the fact of having already been the author or the victim of a misdemeanour or crime. However, the cross-sectional designs used in these studies and the frequency of traumatic antecedents among psychiatric patients make it difficult to know whether violence precedes mental illness or vice-versa. CONCLUSION The relationship between life conditions and victimisation among people with severe psychiatric disorders points to areas in which public health can already intervene. But geographical variation in results may require more local and national studies. The relationship between author and victim and between violence, discrimination and stigma requires more research.

The Practice of Constraint in Psychiatry: Emergent Forms of Care and Control

The work of psychiatry has always revolved around the twin imperatives of care and custody. In an older model of psychiatric power, confinement and coercion were accomplished through isolation from society. The asylum became the ultimate symbol of such power. It arose in the long historical process Foucault termed ‘‘the great confinement,’’ and it reached its ultimate expression in the ‘‘total institution’’ exposed by Goffman in the mid-20th Century. As the landscape of mental health shifted, anthropological attention turned away from the asylum to focus on other topics: psychiatry’s contribution to social control in the neo-liberal state, as practices of governmentality (Foucault 2012), new technologies of the self (Rose 1996) and