IN THE DEPOT NEUROLEPTIC SERIES
FLUPHENAZINE ENANTHATE AND DECANOATE
SQUIBB PRESENTS
PSYCHOTICS IN THE CITY
A COLLABORATION BETWEEN MENTAL HEALTH AND COMMUNITY
(BRON, VILLEURBANNE, MEYZIE & VAULX-EN-VELIN)
AND PROF. GUYOTAT'S UNIVERSITY HOSPITAL DEPARTMENT
VINATIER HOSPITAL (LYON)
WITH THE COLLABORATION OF A PSYCHIATRIST, A GP,
PSYCHOLOGISTS, SOCIAL WORKERS AND NURSES
IMAGES: R. GOSSET SOUND: J. COURTINAT
EDITING: A. LUZUY
DIRECTOR: ERIC DUVIVIER
PRODUCTION COMPANY: SCIENCEFILM
The dangerous ones need to be locked up,
while still being treated.
The dangerous ones, they often perpetrate acts...
They commit crimes and other things.
If you set them free, they'll go at it again.
And if they have families...
The mentally ill can't be cured, Sir.
Because... It depends on their illness, you know?
So...
They stay ill. You can't cure them, whatever you do.
If they're incurable, why would you let them out?
They might...
It could frighten people.
They could meet children if they walk down the street.
It's dangerous.
I think... I'm not a doctor, right?
Some cases... I've seen a few in the neighbourhood,
we're close to Vinatier here, going out for a walk.
There was this gentleman. They said he was from Vinatier.
He looked OK, just walking down the street.
His behaviour was a bit weird.
But,
he had a right to be here.
I'm sure some of them could live at home.
In their families, they recover better.
I think so.
By all means, if they are minor cases,
sending them back to their families would help them recover faster.
But if they're very ill, they should stay in hospital.
If the doctors think it's useful,
I think it's very useful too.
Precautions need to be taken though, to keep dangerous ones away.
I trust them. They must do that.
Maybe it's the best solution to...
At least for some of them.
To allow them a more normal life.
Ultimately, they're locked-up...
They're difficult to cure if they don't lead normal lives.
I'm half for, half against it. There are pros and cons.
You need to realise that it can be a lot for the family.
I know some cases...
In the family, it's... It's no picnic for the family.
I don't know. There's little hope for rehabilitation.
You can't put them back in normal life.
It's dangerous because they're never cured.
- I can't say. - You don't have any opinion?
- No. - About the...
The mentally ill.
No. No opinion.
- What do you think? - Well...
What do you think?
Let me tell you, there are more lunatics outside than inside.
Say what?
There are more sick people out here than up there.
Yes, I was going to say it myself.
I wanted to say it.
I've noticed that... Many things I've noticed...
In hospitals,
the sick aren't nursed properly.
I'm telling you.
We have many victims in France,
'coz they lack...
For the sick, they lack staff, etc.
Efforts should be made. Lots of them.
I'll even tell you my name: Mr Soldini, 22 Ravanel Street.
'Coz I've just lost my wife.
At Vinatier, they treat them well.
And a lot of sick people
are better than those on the outside.
Some are really... They don't let them out.
They don't let them go out at all.
Some sick people, some I know...
Their thoughts are better than those of people outside.
But they're sick, sometimes they...
Some of them... How can I say it?
Some have no relatives.
- There's no responsibility. - No family.
So they're put in there. It's like a death sentence.
If it's interesting for them, it's good, but it shouldn't become...
Don't let it become dangerous for the neighbourhood.
Because
lunatics can be a danger.
If it cured them, it could be interesting.
What a fine mess!
For the minor cases, maybe.
There are dangers.
Don't you think?
And they'd spread out all over the place?
They were institutionalised for a reason, weren't they?
Depressed people, that's one thing but lunatics, really.
What a strange idea!
I haven't heard of it.
Put them in a special village or a secluded area, maybe,
and let them be with people devoted to them,
to get them back on their feet.
But don't let them go around town with just anyone...
POLICE STATION
As police superintendent and for all police officers,
the mentally ill fall within our duties
of public safety and peace.
In Villeurbanne, we are very lucky to have
the Mental Health and Community association.
It brings together doctors,
town councillors, families,
and police officers who wish to partake.
I'm a member.
So are my colleagues from Bron and Villeurbanne.
Some of us are even on the board.
That's how, in regard to the mentally ill,
we can implement
a more nuanced and sometimes more efficient policy.
I don't think institutionalizing them is always necessary.
I've repeatedly called upon the doctor
from the outpatient unit, from the association,
thinking I needed to commit someone.
After examination, the doctor convinced me
that the fit was only temporary,
and that committing them was unnecessary.
TOWN HALL
As the president of the association Mental Health and Community,
I'd like this collaboration to develop
with the population via social centres.
- What's a psychotic person for a GP? - It can be 2 things.
Either an emergency or a psychotic with his family.
The emergency is often an embarrassing one,
a psychotic person we may or may not have been aware of,
and for whom we are called at any time of day and night.
And we struggle to bring them under control
and to have them admitted to hospital.
It's always a tedious situation,
because we need to restrain them,
we need to...
It reminds you of prison a little, of an obligation.
It's unpleasant,
because even for the family,
it makes us look like policemen
coming to lock people up.
There's another, more interesting side to this though,
with issues that are a lot more... A lot less acute.
This is the psychotic person with his family,
who may or may not fit into the family.
I know families
who can tolerate a psychotic family member,
not all the time though.
There are periods of time when he isn't well regarded.
And some families just can't bear him,
even if he comes home only for the weekend.
For a psychiatrist, a psychotic's condition
can be sketched in a simplified way as follows.
I'm representing
the environment here, the surroundings, the community.
Here's the individual.
For a psychotic, the boundary I've drawn here
is blurred and of very unsound constitution.
You could say that for him,
the boundary separating us from the world
has holes in it.
His psyche resembles a sieve.
As a result,
each input from the environment feels like an intrusion to him.
Hence, a notion of being persecuted, of his own body being tempered with.
At the same time, what's inside him
feels like it's pouring out.
Hence the feeling of becoming empty, of suffering losses,
and the vague impression of hemorrhaging out.
So that's our psychotic person in his environment.
What's the origin of this psychosis-environment system?
There is a general consensus that there's a huge problem
between the psychotic and his mother, the mothering figure rather.
What matters is how he views her.
I'm going to draw our patient here.
This is the mother.
You could say that the patient
has an extreme desire of fusion with his mother,
a desire to go back into her womb.
However, this desire feels utterly dangerous to him,
hence the feeling that the mother is dangerous,
that she's a persecutor.
Then he transfers this feeling to his environment.
There are several explanations for this system.
There can be biological causes.
Thus the effect of treatment with neuroleptics, for example.
Apart from potentially faulty biological equipment,
there's the issue of the mother's attitude,
which may feed into the psychotic's anxiety.
Indeed, the mother appears as an almighty, dangerous character,
with the children and father around her,
maybe the doctors, the GP might be pulled into the system.
The mother looks like the manipulator
of all the satellites that are around her.
It may be possible to intervene on this level,
provided that some of the mother's manipulations can be stopped.
We can also intervene
in the relationship between the mother and the psychotic person.
This is the basis for family therapy,
that works with the whole group,
the child or patient, the mother and the whole family.
I was all alone in Lyon,
taking a walk, and suddenly I felt ill.
I didn't feel well.
But I feel better now.
The medication I took in Vinatier has helped,
but there's something else, something psychological.
I had a major blow.
I mean...
My mother didn't really know my real father.
She...
I don't know how to put it.
I didn't really know my real father. It was...
My mother met a boy, she was 19.
19 1/2.
They had sexual intercourse.
It was fast.
They made me the second time.
And then...
My stepfather... My father abandoned my mother.
I'm going to top myself off again.
I feel bad these days.
And...
I was saved.
They saved me. That disgusts to me.
What I find disgusting is our society, really.
So you said that you've been writing poems these days.
I have.
It's about the parable, about the parable,
where...
The Gospel parable.
Christ gives back sight to the blind.
He meets a blind man on his way,
and,
he puts water and dirt on his eyes.
In the poem I analyse this,
as if the natural was coming back, and suffering.
Suffering and the habit of suffering.
And I'm like the One who gives back sight to the blind
Who claims to be on this earth for them
For water and earth are neither in the sinner,
nor in those around him
He must know the purity of water and the pain of the earth, his Mother
Oh Lord, let me be more faithful to the justice of water,
and to my offering to the earth
For I am like the blind carrying the duty of all
Thoroughly washed with water and mud
Designed for him: Water and salt
Purity and bitterness Anesthesia and anti-suffering
Education from our Mother Earth
For you are like the swimming pool or the fishpond
You contain us all like the loving, triumphant mother
And you like to see your creation,
Angular and graceful
I never knew my mother.
And my father...
He left me with my grandmother.
I look upon my mother, my grandmother as my mother.
Until I was 12, I lived with my grandmother.
I spent my whole childhood with her.
And I say it at work, I can say it now, my father was a swine.
It could... You could... For the mentally ill,
you could speak of a new kind of sociology.
It wouldn't be against the others but it could be...
It'd be accepted, let's say. Not impossible after all.
But then there are always some patients against doctors.
They move, they have to act, with a lot of means,
more, to do better, the best they can.
And the outpatient unit's role in the therapeutic system?
Historically,
the hospital represented a kind of fortress,
between the patient and the outside world.
The patient arrived in the hospital.
It was like a second skin to him.
It gave him boundaries he lacked.
The hospital has a therapeutic role here,
in that it provides this kind of security.
The major drawback is that with prolonged stays,
the relationships with the caregivers, let's draw them here,
those relationships normalize, tensions are reset to zero.
Outside, everybody's happy because the patient's inside.
He doesn't disrupt the public order anymore.
And this situation tends to go on indefinitely.
Patients stay in hospital for 10, 15, 20, 30 years,
although it is no longer necessary,
because of the way this system is designed.
When a patient tries to leave this system,
it may go off smoothly,
but if he goes back to the same tensions with his family or surroundings,
he'll tend to return to the hospital to be back in its protective envelope.
Some relapses happen for this reason alone.
How does the outpatient unit fit into this?
The outpatient unit represents, let's draw it here,
a potential fulcrum for the patient who is outside.
It's like an extension,
an approach, a new protective envelope,
a minor one, blended into the community,
more flexible than this very rigid one.
That's what it is.
So the patient going outside
can lean on this second axis, as it were.
At the same time, it provides the patient
with precisely two axes to function.
In the treatment of psychotic patients,
care by two entities seems to be absolutely crucial.
Here's the hospital again,
and here's the patient.
If he's better,
if he's turned the corner,
he's going to be able to lean on two axes,
the outpatient unit,
and the hospital.
Of course, some patients never go to hospital,
and some will never go back to it.
That's why in a second phase or sometimes even straightaway,
what we call co-therapy,
i.e. therapy supported by 2 axes,
can start at once.
This results in a system
with a therapeutic axis here and another there,
which could be independent from either unit, in a second phase.
This could be a psychiatrist,
and here a GP,
acting as co-therapists for this patient.
Or we'd have a psychiatrist and a nurse, a nurse and a GP.
All combinations are possible.
So here we have the co-therapy system,
which seems very helpful with psychotic patients.
However this system has trouble getting set up,
because once outside, the patient tends to reproduce
the system he knew within the hospital.
Even if he didn't know it, that's how he functions.
He views anything within the envelope as good,
and outside as hostile.
When he's back out, he tends to divide the world into 2 parts:
good and bad people.
And so, one of the therapeutic axes
can be continually viewed by the patient as bad,
and the other as good.
As you can imagine,
it's hard to be viewed as bad by a patient you're caring for.
This may cause difficulties between the therapeutic systems,
the outpatient unit and the hospital,
or between two therapists.
That's why co-therapists should meet and share their experience often,
to offload the hostility that may arise,
because of the patient's dichotomy between good and bad.
One of these centres is the outpatient clinic.
It is located in the housing project where its users live.
Social workers, doctors, psychologists, nurses,
meet to talk and coordinate the work with patients at home.
During a first, smaller meeting, an update on home care is made.
... from North Africa. Can you picture him in this?
- Him? No. - Not at all.
It's not only about Villeurbanne. We just don't know what to do.
Maybe try to spend an hour with them? With Kamel and Irène.
I'm not sure about the result,
seeing as he perceives any intrusion like a persecution,
He's defined the good and the bad.
The bad people are at the hospital,
the good is mainly Kamel,
who's taking care of him.
The clinic and I, we're in the middle.
I give him medicine for free, medicine from here.
That's how I'm good.
He calls you Dr. Cardine. He won't call you Marie.
- Rejecting the female part of my name. - Indeed.
Quite fitting for his issues.
It looks like a progressive family deterioration.
They despise one another
because one is more damaged than the other.
The whole family is kind of deteriorating.
I'm not sure...
The line we're following now would be
to act in the neighbourhood, like Kamel does, in the family...
He visits the educator, everybody else,
and he receives medicine in the clinic.
There's no real psychotherapy in place.
That day, they were discussing the social workers' absence.
Absence caused not only by our cameras.
It should be...
We'll decide later on the date. Let's contact the families.
- To see whether they agree. - Yes.
To care for a patient, you need to invest in him,
spend some energy,
take some interest in that work.
Or several people can work together.
I remember several of us caring for Timothée for over a year,
2 years even,
before he went to hospital.
From the day he was in hospital, I liaised with them.
I shared with you what was happening.
He came to the clinic once.
But it happens in the hospital.
The role of the psychiatrist can be perceived badly.
It's still perceived as repressive anyway,
more or less.
The role of the community, of social work is perceived as...
Sometimes I feel as if I'm forever listening to people,
because my technique is different from yours.
Our backgrounds are different.
Listening feels harder than being.
One is said to care for the unconscious,
fantasies and all that.
The other is said to care for reality. We're always afraid of both.
Patients and nursing staff meet
in a support and decision group
It helps solve recurring conflicts,
and serves as a go-between with society.
We agreed you wouldn't go back to work before a set date.
Am I wrong?
That getting in contact with the employer was important,
but that we still had things to discuss.
I'm sick, OK,
but give me work, even hard, never mind.
- No, you can't work now. - December 28th.
You realise how you are, don't you?
- I do. - You're pale, exhausted.
- You need to rest. - I show you, from my boss.
He still has perfusions?
The family unit needs to be treated too.
This is through home psychotherapy.
For others, it doesn't work.
I'm here to see how you're doing.
I prefer the clinic over the hospital.
It was the opposite before.
When Ottmann was in the hospital, that was good.
- It was good for you. - Yes.
- Not for your brother. - I found a job.
For your brother, it didn't work.
We trapped you today, we wanted to see you.
- Annette said you were furious. - What?
She said you were furious.
Yes, I shouted at her.
- You didn't like being trapped. - I didn't.
But I knew it.
Because she said: "Well, tonight..."
It resembled the hospital, talking like that.
It's what
some psychiatrists do.
See what I mean?
I swear it's the same.
Why? I don't quite get it.
I don't know.
Anyway, I don't like it.
We're forcing you to do something,
pushing a sword in your back.
When I left the hospital...
For that psychiatrist...
You don't care to name him.
That one, yes.
We've said it a thousand times.
It's registered now.
You know, the juggler.
If he ever falls on the... That'll please him.
He's Adolf Hitler.
We've talked about that psychiatrist a lot.
What about trying to think about what's happening here?
I love the letter he sent me...
I'm so glad to see you. I have a problem.
Can you remember the kid living with Mrs. Poudret?
I sent her to you 6 or 7 months ago.
You took her on for psychotherapy.
When she feels better, that's why she didn't come back,
she rejects psychiatrists.
She says she's fine.
Indeed, she was ok for some time.
She didn't even consult me for little things.
She introduced her fiancé to me. They seemed to be doing fine.
Now I feel that something is off.
The family doesn't want... There's a problem with the wedding.
The family... They're Pieds-Noirs.
They don't really accept... They don't really like the boy.
I think it's going to rupture.
I wonder how I'm going to bring her to you,
willingly.
The person causing a fuss sometimes forces the social worker
to act as the neighbours' psychotherapist.
- I phoned you about Mr. Martin. - That's it.
- Anything wrong? - Yes.
He's been very noisy lately. Tenants are complaining.
When did it start?
About a week ago.
- Is it substantial? - I think so.
Actually, here's one of our tenants.
Good morning.
I'm a social worker. I'm here about Mr. Martin.
He's not well.
He's very noisy again. He bangs on the walls.
He turns on the taps very loudly.
- And it bothers you. - It does.
Not as much as the first time, when they took him away,
but it's close.
I should go see him.
He's probably in.
It may not be serious. He may have missed his medication.
Home visits
allow conflicts to be discussed in their actual environment.
That's where fantasies and reality reveal their dual faces.
I found something anyway.
- And you still work as a... - A truck driver.
- And your room? - I live alone.
No friends to room with?
Well, I have buddies.
But I like being alone.
What about friends from the hospital?
Those who left at the same time.
At one time, we talked about the possibility
of you going to a post-cure flat.
Yes, I was supposed to go.
Hello, Doctor.
I'm here about the letter you sent me,
about this new injection.
You mentioned it on the letter.
That's it.
What's this injection?
What does it do for my treatment?
I'd like to sort it out once and for all.
That's precisely why we suggested this injection to you.
It's the same medicine you've been taking as a potion.
But instead of taking your potion daily or several times a day,
you'll receive one injection fortnightly.
And this injection, the good it's going to do to me,
is it going to hurt my stomach?
Not at all.
On the contrary. The treatment's going to be lighter.
You won't have to remember anymore
to take your drops, to count them,
to count and take pills several times a day.
Instead you'll come over here to see us,
we can talk for a little bit, see how you're doing,
you'll see the people you know.
And then...
You'll get your injection.
What about my spasms?
Yes. You'll still have to take a tablet against them.
The same you've taken until now. OK?
What if I forget inadvertently?
We have created a little card for that purpose.
You'll carry it in your wallet...
This treatment card
will say that the patient is on depot neuroleptics.
So you've found a job, they helped you.
The aim is not to turn the psychotic into a perfectly adapted fellow.
It is important to prepare him
to accept some kind of return to reality.
But the image of the other, the assigned or spontaneous therapist,
remains a necessary mirror.
- I have to go to work because, look... - Yes?
I used to have a stoop. I was very withdrawn.
When I went to work, I stood upright and stuff.
But through the looking-glass,
there is no Wonderland to be found.
Returning to work remains hard.
... ready to collaborate with us. He's genial.
He's young but I think he's interested.
- The others too, the staff... - Yes.
The loss of a job is often felt as an additional wound.
The social environment often has to be adjusted.
However, we've even met understanding employers,
flowered factories, true bedroom communities,
and adjusted psychotics,
whether workers or managers.
... his coworkers, they started...
- They accepted him well. - They even mentioned him to the head...
- The shop manager. - Yes?
He told the doctor, the social worker.
There's cohesion around him.
- Maybe even too much. - You can't tell them that.
What do outpatient units do?
Some view it as a close, skilfully concealed police control.
For others, it's the medical and technocratic alibi of a civilization
looking for a cure for its discontent.
It's foremostly a practice.
Betwixt individual and social,
its aim is to prevent a breaking off.
However, between the psychotic, the city and their relationship,
who or what needs to be rebuilt?
THE END SCIENCEFILM
Subtitles: Élisabeth Fuchs