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Bureaucratically split personalities: (re)ordering the mentally disordered in the French state

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Abstract

The ability to (re)classify populations is a key component of state power, but not all new state classifications actually succeed in changing how people are categorized and governed. This article examines the French state’s partly unsuccessful project in 2005 to use a new classification—“psychic handicap”—to ensure that people with severe mental disorders received services and benefits from separate agencies based on a designation of being both “mentally ill” and “disabled.” Previous research has identified how new classifications can be impeded by cultural and cognitive barriers to their adoption and struggles between professionals or administrators over their implementation. Drawing on 186 interviews, archival sources, and 13 months of observations across different French bureaucracies, I expand on this literature in two ways. First, I use the case of psychic handicap to argue that a new classification can also fail to achieve its intended effect when it constitutes a bureaucratically split personality—a combination of classifications that imply that individuals belong to two, mutually exclusive kinds of people. I show how psychic handicap embodied contradictory expectations about the behavior, characteristics, and institutional trajectory of people with mental disorders. Second, I identify how bureaucrats resolved these contradictions through mechanisms of refractory looping, outsourcing expertise, and classification by default, which in this case led to the reclassification of this population as simply “mentally ill.” This framework calls attention to how practical inconsistencies can limit the impact of new classifications, even absent overt resistance to their elaboration or implementation.

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Notes

  1. I use “severe mental disorders” to refer to the disturbances of thoughts, emotions, and behaviors usually associated with serious forms of conditions like schizophrenia, bipolar disorder, or major depression; these disturbances are then typically classified as “symptoms” and labeled “mental illnesses.”

  2. Handicap” in French can be translated as either “disability” or “handicap.” For clarity, I use “psychic handicap” (“handicap psychique”) to refer to the specific category advanced by advocates for people with mental disorders and “disabled” to refer to the broader administrative classification that could contain people with “physical,” “intellectual,” “sensorial,” or “psychic” handicaps. All translations are by the author.

  3. République Française. 2005. Loi n°2005-102 pour l’égalité des droits et des chances, la participation et la citoyenneté des personnes handicapées. Retrieved October 4, 2017 (https://www.legifrance.gouv.fr/).

  4. This shift is visible in the national ministerial strategy, which talks more about “avoiding” psychic handicap than giving benefits based on it. See, Secrétariat d’État chargé des personnes handicapées, 2016, Stratégie quinquennale de l’évolution de l’offre médico-social: Volet handicap psychique (Paris, France).

  5. See, Comptroller General of the United States, 1977, Returning the Mentally Disabled to the Community (Washington, DC).

  6. Maryl and Quinn (2016, p. 5) refer to this as “boundary activation” (see Lamont and Molnár 2002).

  7. Forced treatment for mental illness is a notable exception.

  8. Navon and Eyal (2016, p. 1426) describe how looping with respect to autism “disabled” other interpretations of children’s condition. This terminology would be confusing in this article, and those authors’ use of the term does not consider competing classifications per se.

  9. I also obtained unpublished statistics from the Disability Office, which show that the cases I directly observed were representative of the broader range of demands treated by the Disability Office and of their outcomes.

  10. Direct observation of decision-making over access to downstream services for housing and employment was not practical, because many structures (such as a fifty-bed nursing home) would only admit one or two new people per year.

  11. This focus on observable responses to a classification rather than phenomenological experiences of being classified is consistent with other studies on “looping” (Eyal 2013; Navon and Eyal 2016).

  12. The remainder, mostly in advocacy organizations, had educational backgrounds not directly related to health, disability, or public policy.

  13. See, Ministère de la santé publique, Circulaire du 15 mars 1960 relative au programme d’organisation et d’équipement des départements en matière de lutte contre les maladies mentales (Paris, France).

  14. Both “disability” and “health” are covered by the (frequently renamed) Ministry for Health and Social Affairs, but in separate directions. For simplicity, I speak of the “health” and “disability” ministries.

  15. See, Ministère de la solidarité nationale, 1983, Bilan de la politique en direction des personnes handicapées (Paris, France).

  16. See, Direction de l’hospitalisation et de l’organisation des soins, 2008, “Éléments d’analyse des inadéquations de prise en charge en hospitalisation complète,” DGOS 2014 / 011 / 3.

  17. See, UNAFAM. 2001, Le livre blanc des partenaires de Santé Mentale (Paris, France), p. 12.

  18. See, Chirac, Jacques, 2002, “Discours devant le Conseil national consultatif des personnes handicapées” (Paris, France), retrieved August 19, 2016 (http://discours.vie-publique.fr/).

  19. See, République Française, Loi n°2005-102, article 3.

  20. See, Fédération d’aide à la santé mentale, 2016, “Égalité, citoyenneté et handicap psychique,” Pratiques en santé mentale 1(February), p. 84.

  21. Présidence de la République, 2014, Conférence nationale de handicap: relève des conclusions (Paris, France), Service de presse, retrieved June 26, 2016 (http://www.elysee.fr/).

  22. Massé, Gérard, 1992, La psychiatrie ouverte: une dynamique nouvelle en santé mentale: rapport (Paris, France), Ministère de la santé et de l’action humanitaire, p. 234.

  23. République Française, Loi n°2005-102.

  24. L’agence nationale de l’évaluation et de la qualité des établissements et services médico-sociaux, 2016, Spécificités de l’accompagnement des adultes handicapés psychiques (Paris, France), p. 27.

  25. Caisse nationale de solidarité pour l’autonomie, 2017, Troubles psychiques: Guide d’appui pour l’élaboration de réponses aux besoins des personnes vivant avec des troubles psychiques (Paris, France), p. 16.

  26. Caisse nationale de solidarité pour l’autonomie, 2009, Handicaps d’origine psychique: Une évaluation partagée pour mieux accompagner les parcours des personnes (Paris, France), p. 64.

  27. Hardy-Baylé, Marie-Christine, 2015, Données de preuves en vue d’améliorer le parcours de soins et de vie des personnes présentant un handicap psychique, Centre de Preuves en Psychiatrie.

  28. Haut Conseil de la santé publique, 2014. Enquête quantitative sur les modes d’évaluation et de traitement des demandes de compensation du handicap par les MDPH (Paris, France).

  29. Caisse nationale de solidarité pour l’autonomie, 2017, Une réforme tarifaire pour faciliter les parcours des personnes handicapées (Paris, France), p. 2.

  30. 15.8% of these allowances were given to people with psychic handicaps, even though they constituted closer to 25% of total applicants for disability benefits. Amara, Fadéla, Danièle Jourdain-Menninger, Myriam Mesclon-Ravaud, and Gilles Lecoq, 2011, La prise en charge du handicap psychique (Paris, France), Inspection générale des affaires sociales, pp. 30, 70.

  31. Calculation based on Social Security Administration, 2015, Annual Statistical Report on the Disability Insurance Program (Washington, DC).

  32. Unpublished statistics (see Note 9).

  33. A key example was “Potentiel Emploi,” a national experimentation in a detailed evaluation of working capacity centered on people with psychic handicaps. The experiment was not renewed.

  34. Le Houérou, Annie, 2014, Dynamiser l’emploi des personnes handicapées en milieu ordinaire (Paris, France), Assemblée Nationale, p. 24.

  35. UNAFAM, Le livre blanc, p. 12.

  36. Agence régionale de santé, 2011, Projet Régional de Santé: Schéma d’organisation médico-social, Île-de-France, p. 45.

  37. OECD Health Statistics, 2012, retrieved September 13, 2017 (http://www.oecd.org/els/health-systems/health-data.htm).

  38. Direction de la recherche, des études, de l’évaluation et des statistiques, 2013, Les établissements et services pour adultes handicapés: Résultats de l’enquête ES 2010 (Paris, France), pp. 269, 273.

  39. MDPH 75, 2014, Rapport d’activité (Paris, France), p. 61.

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Acknowledgements

The author gratefully acknowledges the assistance of Martin Eiermann, Gil Eyal, Neil Fligstein, Marion Fourcade, Matty Lichtenstein, Michael Long, Mara Loveman, Marie Mourad, Isabel Perera, Gisele Sapiro, Tonya Tartour, two anonymous reviewers, and the Theory and Society Editors, as well as the Culture Organizations and Politics Workshop, Berkeley Medical Sociology Working Group, the Berkeley-SciencesPo Collaboration Conference, the Columbia Science Knowledge and Technology Working Group, and the Center for European Sociology. A version of this article was presented at the 2017 ASA Annual Meeting in the Regular Session on Health Policy. Research was made possible with the generous support of the Chateaubriand and Georges Lurcy Fellowships and the Institute for International Studies and Center for European Studies at Berkeley.

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Barnard, A.V. Bureaucratically split personalities: (re)ordering the mentally disordered in the French state. Theor Soc 48, 753–784 (2019). https://doi.org/10.1007/s11186-019-09364-2

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