Contenu du sommaire : Handicap psychique et vie quotidienne

This article aims to shed light upon the conditions under which the notion of psychic handicap developed so rapidly over the past fifteen years by looking back upon the evolutions in psychiatric reflections on handicaps deriving from mental illness, from the years following World War II through the 1980s. This reflection, which is linked to the realization that suffering from a mental illness makes it difficult to participate in society yet that these difficulties are indivisible from the morbid processes, has, over the course of this period, led psychiatrists to begin an ensemble of projects and experiments ranging from group psychotherapy to creating specific geographic psychiatric sectors, from non-hospital assistance to professional re-adaptation, and is at the crossroads of psychiatry and handicaps. For all that, these experiments have been riddled with persistent tension concerning the meaning and limits of the re-adaptation psychiatrists have initiated, and this tension came to the surface after a law was passed in 1975 that created a new context under which the concept of the psychic handicap has expanded rapidly.

Living with a psychic handicap at home. À statistical approach to practical arrangements. Although the 2005 law on handicaps confirmed the concept of psychic handicap, it barely touched upon creating a precise definition thereof that refers to the consequences of mental disorders in terms of daily limitations in a given environment. In order to give this hard-to-define new entity substance, most studies have chosen to use medical or administrative variables as indicators being that they are easily workable, such as regular psychiatric care or having frequented psychiatric institutions. The practical arrangements approach this article proposes is different being that it is based upon daily incapacities and the access to care declared by a large sample of people with health problems within the framework of the Handicap-Incapacités-Dépendance survey conducted by INSEE in 1999 on people living in ordinary households. The existence of regular psychiatric care thus appears to reveal specific situations proper to psychic handicap that are but one of this phenomenon's many facets, and which the authors explore here by using diverse statistical tools (notably logistic regression and factorial analysis). Alongside the mental disorders that could be referred to as supervised, are others only necessitating the family's management of said disorders, which makes them less visible.

The difficulty of quantifying psychic handicap. From classification to surveys. The more and more frequent acceptation of the concept of psychiatric psychic handicap is accompanied by the need for a precise delimitation of the nature and number of the population concerned. The difficulty of estimating the handicap's prevalence in general is notably due to its multi-dimensional nature and to the fact that each of these dimensions is part of a continuum. In the domain of mental disorders, the historical context of the emergence of the concept of psychic handicap probably contributed to the proximity of this entity to that of mental illness. The appreciation of a prevalence necessarily relies upon conceptual tools that aim to understand this phenomenon. The International Classification of Diseases (ICD), of mental disorders (DSM), and of handicaps (CIH and ICF) as well as survey questionnaires based on these classifications demonstrate these tools' partial overlap, which complicates obtaining an univocal quantification of psychic handicap in the general population

At the boundaries of psychic handicap. The genesis and use of medico-administrative categories. Borderline cases are particularly instructive in understanding exactly what is at stake in defining a health problem as being a psychic handicap. Through an analysis of ethnographic cases, we aim to examine the borders between the concepts of psychic handicap, with mental handicap on one side and cognitive handicap on the other. Starting with thoughts on the genesis of the medico-administrative categories used in these domains and a detailed exposé of two cases, one of which concerns an adolescent referred to as mentally handicapped, the other concerning an elderly person having been treated at a memory clinic, the authors will question the links between classifications of age and of pathologies. The confrontation of the genesis of these medico-administrative categories and the practical categories, that is, distinctions made by people in direct contact with a handicapping health problem, enables us to question the concept of psychic handicap beginning with these borderlines, where medical evidence blurs and where there are numerous conflicts in the definitions made by the different players.

The quality of life of people suffering from schizophrenia. À study in daily life. The subjective quality of life is an essential dimension of psychic handicap. It is nevertheless rarely directly studied in daily life, likewise for its relationship with minor life events. The goal of this research is to study the subjective quality of life of subjects suffering from schizophrenia using a new method of computerised data collection in daily life (EMA : Electronic Momentary Assessment). 40 subjects suffering from schizophrenia and 43 control subjects answered electronic questionnaires 5 times a day for 7 days. The results confirm that there is a lower global subjective quality of life for people suffering from schizophrenia and specify that interpersonal relationships constitute the main domain of dissatisfaction. Events reported as important by the control group are the same type as those reported by the schizophrenic group, with the exception that, in this group, events concerning health matters dominate daily life. Finally, the results show that, contrary to the control group, the schizophrenic group's subjective quality of life is not often linked to the impact of events in daily life. These results call for further research into the mechanisms underlying the evaluation of the subjective quality of life for people suffering from schizophrenia.

Cognitive reeducation. An evaluation of results. Cognitive sciences now enable a renewal of the biopsychosocial approach to treating people suffering from schizophrenic disorders. After a brief historic overview, the authors will present the main data concerning the new approaches to “cognitive reeducation” or cognitive remediation. Cognitive remediation differs from cognitive behavioural therapy (CBT), which targets thought process and content, in that it targets the fine grain of mental operations (the cognitive processes) enabling the emergence of thought. Diverse practices were developed using the observation that it was possible to improve patients' cognitive performances as a starting point, the principles of which are presented and illustrated herein. Globally, solid arguments now exist as to the efficacy of these therapies and certain key factors of their ecological impact are discussed. The perspectives opened make it possible to hope that these therapies could one day be offered to as many people as possible.

Living with a psychic handicap. Therapeutic apartments. In certain psychiatric sectors, the teams dispose of therapeutic apartments that they can offer to certain patients for rental, associated with obligations in terms of treatment. At the crossroads of medical treatment and social support, such structures show the true tension linked to the redefinition of the perimeter of the psychiatric sector's expertise as regards the treatment of people with severe mental disorders. Having access to such a resource is a real opportunity for the patients, notably following a social rupture, but, by committing them to psychiatric treatment, it also has a practical and symbolic cost. By precisely analysing the way in which therapeutic apartments function using ethnographic observations and interviews, we can see how healthcare professionals and patients negotiate working towards autonomy and social integration. Oscillating between two relational frameworks, one being a contractual relationship and the other being a therapeutic relationship, healthcare professionals adjust their expectations and the obligations so as to make the patient autonomous. However, it is always possible to return to a less demanding position when they deem the illness to be dominant.

This article analyses the autonomisation process of young people suffering from mental disorders as they move into adulthood. It shows that autonomisation brings the idea of the youth's identity into play, as well as the relationship between said youth and their family, but also that it is indivisible from collectively managing the mental illness, that is, societal issues defining the autonomous individual and the options of policies concerning both the young and the handicapped. The path to adulthood rarely manifests itself as a series steps to take or as a linear evolution towards independence, but rather comes from research, experimentation and new interdependent relationships beginning with facing the mental disorder.

Psychic handicap”, the paradoxes of recognition and ordinary knowledge among people with severe mental disorders. In France, despite the mobilisation of health consumer organizations, people with severe mental disorders (PSMD) have yet to consolidate shared knowledge of their condition. Rather than employ the still unstable official definitions of “psychic handicap”, a notion akin but not equivalent to psychiatric disability, this article shows how through verbal exchanges, subjects can produce elements of a uniquely patient-based knowledge about the lived effects of their illness and its interaction with context and everyday life. Using perspectivist principles and modified conversation analysis, we conducted and analyzed collective interviews with members of both Mutual Aid Groups (MAG) and hospitalised patients. This allowed us to capture major aspects of shared consumer experiences, as both source and effect of disability. For these subjects, the invisible quality of psychic handicap becomes an obstacle to re-entering the realm of the “normal”. Finally, the effects of treatment, of relationships and of administrative management, constitute, according to the interviewees, a double, or substitute “handicap”, like the iatrogenic disability caused by medication effects. Patient knowledge thus clarifies how official recognition of the category the psychic handicap runs the risk of reproducing the very phenomena it aimed to diminish, namely stigmatisation and marginalisation.

Cognitive deficits and the difficulty of professional integration for people with schizophrenia. Having difficulties with professional integration is one of the major characteristics of the psychic handicap linked to schizophrenia. Cognitive disorders and clinical symptoms are the main cause. However, little is known about the nature of their relationships with professional integration. This article presents the results of a study examining the influence of amnesic functions and negative symptoms on five components of behaviour at work that was carried out on 39 people with schizophrenia in professional reintegration. The second part of the study presents a personalised approach to cognitive remediation that targets objectives directly linked to the person's professional and/or daily life difficulties. The programmes concerned mnesic functions and attentional control. Analyses indicate that long-term verbal memory influences cooperative abilities, the quality of work and personal presentation. The ability to learn verbal information plays a role in work habits. The working memory that enables processing and retaining information in the short term does not appear to influence behaviour at work. Finally, the negative symptoms partially determine social skills and personal presentation. The results of cognitive interventions demonstrate their efficacy in compensating cognitive deficits in social and professional integration.

The problem of professional integration for people with a psychic handicap. The different dimensions to consider. Although evaluation and support practices in professional integration for people with a psychic handicap are, for the most part, ensured by clinicians, they need a theoretical framework that accepts the multidimensionality of factors that play a role in professional reintegration, and thus cannot be limited to a clinical and psychopathological frame of reference. The empirical research predicting the factors of a return to employment or evaluating the functional effects of psychiatric disorders highlights the fact that psychopathological evaluations and cognitive performance evaluations are insufficient when considering the possibilities of professional reintegration, which reiterates the need to specify the other pertinent dimensions. Other works on the concept of rehabilitation or factors aiding people to overcome the handicap insist upon the need for a model specific to the handicap, distinct from the medical model and attentive to its situational nature and to resources of the persons' subjectivity. Using literature, we will evoke a few other dimensions to consider. The multidimensionality of factors implicated in reintegration demands a multidisciplinary approach of research, but also requires multidisciplinary treatment for reintegration evaluation and support practices.

The meaning and use of mental disorders in the sector of socioprofessional integration. The example of the city of Toulouse. The 2005 law on Equal Rights and Opportunities, Participation and Citizenship for People with Disabilities does not content itself with adding psychic handicap to the already recognised handicaps. It also opens a breach in the territorial management of the handicap. In fact, working for social involvement and citizenship for disabled persons requires calling all integration professionals – whether they are involved in the beginning or end of the institutional recognition procedures. However, although the law brings to mind provisions instituted by national and European directives, it makes no mention of the terms of the work accompaniment structures' involvement. Consequently, how do they grasp this question? Starting with the example of the city of Toulouse, this article demonstrates how, alongside medico-administrative expertise and legislative productions, specialised and non-specialised structures define mental disorders using their own interpretive frameworks dependant upon, on the one hand, the way in which they use an integration model that is based on the “government of self” and, on the other hand, the positions occupied in a particularly fragmented and competitive sector.

Job retention for people suffering from a psychic handicap, an organisational challenge for the company. Large companies are confronted with the problem of job retention for employees with psychic handicap in their workplace. They observe their lack of means and knowledge to accompany these people who are fragile in their workplace and whose relationship to employment changes throughout their career. This situation is exacerbated by the confusion surrounding psychic handicap. The history of its recognition is singular. As they are difficult to define, cannot always be observed objectively by doctors, and are the object of political and social issues, psychic handicap are becoming an emergent question for organisations and pose the question of their recognition which cannot be limited to a questioning centred upon the person but must lead to a reflection on the company as a whole beginning with analytical frameworks of organisations' sociology. How can the company as an organisation generate conditions favourable to the recognition of psychic handicap and the accompaniment of these people?