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Friday, 23.07.2021

Jean-François Dreyfus: My early years in psychiatry 1968-1973

 

        Many distinguished authors insist on the need to separate microhistory, more or less one's own recollections, and macrohistory, more or less the way history is described in textbooks.

        Here are some of my recollections of the period starting in 1967 and ending in 1975. It corresponds roughly to the time when I was trained in psychiatry and psychoanalysis.

        When I started my medical studies, the curriculum lasted for seven years. Psychiatric specialization required four more years of training for which, courses were also dispensed by the Academic Department of Professor Jean Delay, at Hopital Sainte-Anne, who had achieved world fame by discovering the taming properties of chlorpromazine in mentally ill patients. There was one exception: for historical reasons, neuropsychiatry was also taught in the Neurology Department at La Salpétrière.

        As to practical training, during the first three or four years you were just (unpaid) attendants in hospital departments. There was then a classifying examination and those succeeding became (paid) junior residents for six to eight 6−month terms. Positions were chosen according to seniority then exam rank. As to psychiatrist, once you had completed your junior residency you could take a new classifying examination that promoted you to the (better paid) status of senior resident, which you could enjoy for three to four yearly terms. Again, positions were to be chosen according to seniority and examination ranking. During their last year, senior residents very frequently were recruited as Deputy by Department Chiefs and left to start their career in public asylums.

        In France, WW II had a lasting impact on “corrective” institutions. Physicians who belonged to the “Résistance,” mostly progressists, put up a system called “sector” in order to prevent hospitalization. This system was conceived as a preventive net over every territory and took care of patients on a day-to-day basis. This approach had little contact, if any, with Academic departments. The former considered the latter as stuck in byzantine controversies on vocabulary and drug properties and the latter considered the former as utopists.

        Now that the stage is set, let me jump to my recollections. My fifth term as a junior resident was due to start in early January 1968. Having tried various fields of somatic medicine, I had elected to go for a term in psychiatry. I was 23 and had no experience in the field. I was supposed to get my MD at the end of the semester, so as to be able to replace colleagues in their practice and earn enough money to get married. However, in the fall of 1967, my future brother-in-law, a graduate of École Polytechnique, a very prestigious institution, told me that computer science was a promising field in medicine. As a notice announced a presentation of this topic to students a few days later, I decided it was worth attending. To cut the story short, it so happened that the Head of the Department where I had been a junior resident for the last semester, coming in late to this meeting, sat next to me by chance. At the end of the session, quite surprised to see me there, he wanted to know if I had an interest in the field and told me that he could obtain, starting after the 1968 summer holidays, a grant for a 1-6-year university training in the domain, which, of course, I accepted; by the end of 1968, I was very busy trying to catch up with maths, logics and programming at the Paris Science Faculty science, which has had a major impact on my professional career.

        There were few possibilities to get acquainted with psychiatry. The academic departments, some far away suburban hospitals, were very inconvenient to reach; fortunately I was able to secure a residency position at the Psychiatry Department of the Paris Hospital of the International University Campus (HICU), a semi−private institution that dealt mainly with foreign students who came to study in Paris.

        At HICU, treatment was resolutely psychodynamic. Dr. Hubert Flavigny had enlisted two very experienced psychoanalysts as his assistants. The “storm” of May ‘68 disrupted everything, and I have to admit that I was one of the main disruptors. With a low−ranking member of the nursing team, we created, in these small, quiet precincts, a revolutionary committee, which was later converted to a leftist trade−union, still active today. By the end of May, when everything returned to “normal,” I was summoned by Flavigny and asked to leave the department as soon as possible.

        I had fallen in love with psychiatry and was senior enough to choose a position in Delay’s department, but when my turn came, there were no longer any available. Finally, I went to hematology and came close to becoming a hematologist.

        Holidays, marriage, replacing physicians, Excellence Insititute at the Science Faculty: by September, I had almost forgotten Flavigniy and the HICU when I received a mailer inviting me to attend an information meeting to be held by Flavigny at the HICU psychiatry department. There were about 40 former junior residents present and Prof. Flavigny explained that he had been appointed professor in one of the new universities that were created as a result of the student riots. If his position was to be maintained, he had to start a training course almost immediately and he wanted to know if any of us was interested. Most of us were, and there was a random draft. Twenty slots were open and I was the 19th drafted. Thus, I started my psychiatry training.

        At the end of this first year of training, there was the competitive examination for a senior residency in psychiatric “sectors.” To my surprise, I came out second and it was difficult not to seize such an opportunity. At that time I lived outside of Paris, not too far away from one of the “sectorized” hospitals, one that had been built less than 10 years before and that had the reputation of being one of the best examples of “institutional psychiatry.”

        As one can understand, I had no real practical experience.

        In the fall of 1969, senior residents had been on strike for almost a year and they boycotted the drafts that occurred every year to renew the hospital psychiatric staffing. This led to an awkward situation as the most experienced senior residents, for instance, those who had been nominated as Department Chiefs in other regionals “asylums,”  wanted to leave and take their new positions. A compromise was found: the fourth−year senior residents were to leave and only those positions that had been vacated by their departures would be included in the forthcoming draft. This meant that I was granted a position that usually belonged to the most senior residents while at about the same time I started my own psychoanalysis with a rather prominent Lacanian analyst and was only in the midst of my second year of psychiatry training.

        With no experience at all, I found myself in charge of two wards, each with about 25 patients. In addition, the Department Chief had a motto: “I am present through my absence.” At the end of 1970, I had gained some limited experience when the hospital director told me about her grand project: fully converting one of my wards into an institutional therapy unit; she had already selected what she considered to be the best psychiatric nurses to staff this experiment and felt that I would be the right person to carry out this project. Of course, I accepted.

        I had no idea what “Institutional Therapy” was. Through reading, I became aware that teams in the UK, Italy and Scandinavia had other approaches to mental health care. I read Laing, Cooper and Battaglia, Gentis, Oury and Tosquelles and armed with my own interpretations of their concepts led our little team on unexpected roads to become, as far as I know, the only functional experiment of antipsychiatry in a public mental hospital in France.

        Antipsychiatry has many flavors. What were ours?

1) Build some consensus on the approach to be used. We were given a full week of non−stop discussions to come to a common way of thinking about “madness” and how it was not to be dealt with. In particular, offensive public comments on patients’ behaviors were to be banned.

2) Only admit to the ward patients who were voted in by nursing staff and resident patients. Newcomers were to agree to a less paternalistic approach of their difficulties.

3) Promote our own approach to the patients even if it broke the rules of the hospital. We even considered demolishing the hospital fence to have our own access to the outside world.

4) Resort to our own resources even in case of emergencies and leave out as much as possible the administrative procedures and resources of the “asylum” so as to make both patients and team more self−reliant.

5) Provide continuous theoretical training on mental disorders to patients and staff. Self−development was also recommended and associations, students and universities were approached to provide it at affordable costs.

6) Hierarchy based on a supposedly better theoretical appraisal was abolished. Any team member could spend therapeutic time with a patient; even other patients in the ward were called in a therapist role if it was felt they had a better relationship to some patients.

7) Compulsory antipsychotic treatment was discontinued, but patients were strongly encouraged to take it on a voluntary basis. Pros and cons of these treatments were a regular topic for the weekly ward assembly. However, the Hospital Director was informed when we had doubts about a patient’s evolution and when she came for rounds − which became less and less frequent with time. However, we made it clear that her only possible decision if she disagreed with the way we were dealing with a patient was to decide to reinstate a patient to a “normal ward,” which she never did.

8) No alcohol would be allowed on the ward, even for festive events, and this rule was only broken once, after being specifically discussed by the general assembly, on New Year’s Eve. Of course, no addictive drug was allowed in the ward although Mandrax® was still easily available.

9) Conversely to what took place in other wards, the doors of our building were always open and no curfew nor any permissions to wander in the huge hospital park were required.

10) Patients were invited to participate in activities such as therapeutic groups, ergotherapy, cultural visits and sports. A social worker came every two weeks to help patient’s reintegration. However, no specific deadline was set for their return to the outside world.

11) Every institutional decision was made in general assembly meetings that took place at least once a week but in some periods were conducted on a daily basis. Most decisions led to a vote in which patients' votes were put on the same par as staff's ones.

12) Most therapeutic sessions were video recorded (I happened to have one of the first camcorders available to amateurs worldwide) and could be replayed, to improve our practices in specific training sessions.

13) Admission of new patients to the ward, as proposed by other wards, was subject to a vote after the newcomer had spent several hours in the ward to discuss the move with other patients and staff.

14) Sex (the ward was mixed) was authorized with four caveats: it was to be freely consensual; it was not to hamper other patient’s lives; sex between members of the nursing team was not allowed in the ward; and sex between resident patients and staff was prohibited in the hospital compound.

        Most certainly there were certainly other rules and procedures but 50 years later, with no written documents available, I may have missed some other important ones.

        No patient was admitted directly to the ward. They were each referred by one of the six “normal” hospital wards. Initial recruitment was slow but progressively increased and we reached our full capacity of 25 patients after about six months of operation. However, we had reasons to suspect that wards proposed some of their most difficult patients just to get rid of them.

        Most of these referrals were psychotic patients. Some of them with florid delusional states, some of them with residual schizophrenia. All of them were anticipated to remain inpatients for several years. In a few cases, symptoms were aggravated by severe alcohol addiction. None of them, however, was considered dangerous and none was hospitalized on authority’s orders.  A few cases of paranoid delusions and chronic (hypo)manic states completed the sample.

        Over the 16 months of the ward’s existence only two patients left hospital, an outcome that matched the general hospital record for such patients. Two more patients found a regular working position (with a salary) inside the hospital. No patient deteriorated to the point of being sent back to a closed ward. Treatments levels were drastically decreased. One patient committed suicide after being denied access to his children by his former spouse.

        Administrative difficulties started right after the ward was opened and a long−waged guerilla war started with administration and other wards.

        Patients were found wandering at night in the hospital and other teams felt it dangerous. Patients were found having sex outside the ward and this was considered shocking. In both cases we refused to take any offensive action.

        The gatekeepers refused to let patients out without a “leave” formulary. To prevent patients from jumping over the hospital walls, we responded by preparing blank pre-signed formularies that anyone could access on demand. Normally, meals were brought from the central kitchen at prespecified times and trolleys were collected one hour later. Since we were unable to have this routine changed, we requested to receive our share of food unprepared and uncooked. From that time on, the ward’s kitchen became an active place. Everyone was to perform some domestic tasks and I remember the disapproving glance of the Director when he found me with a broom dusting a patient's room.

        Every patient got at least half a day of personalized therapeutic interaction per week, three or four times more than in a “regular ward.” All in all, we demonstrated that even such patients could be dealt with as human beings without repressive containment. One sure sign that this “worked” was that one after another, parents started to come and visit and even children came to see and play with their hospitalized mothers or fathers.

        All this came to an abrupt end.

        A young woman, about 25, severely delusional and clearly ambivalent was admitted to the ward. She was quite attractive and attracted most of the males. One evening, after she had refused the advances of two patients, both went out to the local pub and came back quite drunk and sexually excited. They wanted to enter the room of their prey. Two nurses, a man and a woman, denied them access to her room and ultimately barricaded themselves with her in her room. The two drunkards announced that they would smash everything in the pavilion if they were not let in. None of the patients felt strong enough to confront them; the two nurses did not give in. The other pavilions while on alert did not call the emergency intervention team.

        The next morning, when called by the incoming nursing team, I arrived to find not a single windowpane left intact, the TV smashed and all wooden furniture reduced to fragments. In the hospital, the scandal was enormous and teams from other wards gathered in front of the devastated building while some patients had already started cleaning the floor.

        The Hospital Director, without making any investigation, called a meeting and announced that she had decided to terminate the experiment and close the pavilion. All nursing staff and patients were to go back to their former positions. I was asked to take a leave immediately and was told that she would not accept me as a resident if I dared to come back on the next draft. Patients were anxiously waiting for us to come back from the meeting.

        We then had our last general assembly and, when confronted by the Director’s decision, the patients unanimously decided that they would lock themselves with us in the pavilion and go on a hunger strike.  We refused. We argued that, after all, we were a nursing staff and that they were patients. We could not let them endanger themselves through a hunger strike. After all, we were not those irresponsible persons the Director had depicted, and we would vouch for those who were far less rational than us. Although a few voted to stay and despite the unanimous vote of the patients, we reluctantly left.

        I ended up with a very poor reputation and since I had one or two additional residency terms to complete, I picked a new position in the psychiatric unit in a general hospital. On my very first day, the Head Physician, who was never present, came to me and took me for an interview in his office; he clearly notified me that if I dared disrupt the successful routine he had initiated, he would just fire me.

        One may think that this ends the story but as we love saying: “Impossible n’est pas Français!” Three years earlier: before the Senior Resident Examination, to validate my last term as a junior resident I had managed to do this term in Pierre Pichot’s department. His department was created on the ashes of the former Delay’s department: one department was for Pichot (retaining the former official denomination: Clinique des maladies mentales et de l’Encéphale) and one for Deniker.

        Pichot did not think I was a good psychiatrist, although subsequently he became more friendly, but he loved my statistical and computer abilities. While being considered by many as a dangerous rebel, I stayed in his department for more than 12 years as a dilettante part−timer, under various titles being more or less responsible for methodology, statistics and computing. And he liked me.

        In 1973, we received a grant from the army for a pilot study on the feasibility of using computers to automate questionnaires on the personality of officers−to−be. Interviews with psychiatrists were compared to results of computerized questionnaires completed by the same individuals. The study was considered so advanced that even the national TV came to make a film of us. As I needed to produce a graduation paper for psychiatric specialization, Pichot suggested that I could report these preliminary results, which I did.

        However, there was still strong antagonism between various groups in psychiatry, in particular between psychotherapy−oriented groups, such as those of Flavigny’s heirs, and those evolving towards a more hard−science oriented approach, with Pichot among them. When I presented my work to the jury of psychodynamically oriented psychiatrists (at that time they still considered me as “The Antipsychiatrist”). They all believed that I had changed sides and was now a tenant of the opposing school. Fortunately, Pichot, at that time, was at the acme of his influence. Before flunking me, the President of the Jury phoned him. I do not know exactly what was said but I was later told that Pichot requested that they let me pass. All the other candidates were awarded a pass mark one level higher than mine, just to make clear how my judges disagreed with the approach there reported.

        “But Dreyfus, why on earth did you participate in the antipsychiatry project and then in a depersonalizing approach with computers?” Answered Dreyfus, somewhat too ironically: “Because I found them amusing!”

 

July 22, 2021