Effraction d’un cadre psychothérapique en milieu carcéral et décompensation psychotique

RésuméEn France, la responsabilité et la mise en œuvre des soins aux personnes incarcérées sont, depuis 1994, assurées par le service public hospitalier, sous la forme d’Unités de Consultations et de Soins Ambulatoires (UCSA) implantées dans les établissements pénitentiaires. Le personnel de ces unités doit composer avec l’omniprésence de la logique sécuritaire et normative propre au milieu carcéral. Dans ce contexte, le cadre de la prise en charge psychothérapique d’un détenu n’est pas à l’abri d’« attaques » extérieures. Ainsi, une rénovation mobilière sans préavis d’une pièce où travaillait une psychologue a provoqué une décompensation psychotique chez un détenu. Cette occurrence illustre la nécessité de prévenir par la confiance et l’explicitation mutuelles des tâches entre soignants et surveillants les passages à l’acte par lesquels le personnel pénitentiaire exprime parfois sa difficulté à admettre une logique de soins dans ses murs.

The objective of our study is to prevent pathological outcomes of the institutional abuse in a prison facility, which can trigger a psychotic breakdown of inmate patients, by enhancing a healthy communication between penitentiary staff and medical team despite the fact that they both adopt two opposite approach of inmates. In France, since 1994, public health institution took in charge medical and psychological penitentiary follow-up through Counseling and Ambulatory Care Units (UCSA). Composed of a multi-field team (psychiatrists, psychologists, medical staff), those care units have to constantly deal with security and normative issues specific to the prison facility. Usually, it is difficult to keep the psychotherapy setting safe from external “attacks” inflicted by penitentiary staff. Moreover, admitting UCSA within prison walls raises the eternal conflicting issue between two opposite logics: punishment (related to guilt) and treatment (related to illness and suffering). Whereas, UCSA staff perceives inmates as patients (to be cured), penitentiary staff perceives them as “cons” or out-laws (to be punished). The daily confrontation of such opposing logics not only affects the quality of communication between health team and penitentiary staff, but it also triggers acting-outs which put to the test the feasibility of psychotherapy in a prison setting mainly with mentally vulnerable inmate patients. Our method is based upon a case study of an inmate patient, C., who suffered a psychotic break down as a consequence to the unannounced renovation of the office dedicated to his psychotherapeutic sessions. Though, it is true that C., a former addict, had already a psychotic predisposition, his encounter with the intrusive and arbitrary authority of the penitentiary institution triggered his mental breakdown while undergoing psychotherapy. The result of our study emphasizes upon the necessity to establish a true communication between the medical team and the penitentiary staff and a mutual understanding of the value of their professional task in order to contain any conflict issues or misjudgment that may affect the progress of the most vulnerable inmate patients. Our study concludes to the importance of a complementary, cooperative, comprehensive and balanced approach of mental health problems in a prison facility through continuous training courses and discussions involving both penitentiary staff and medical teams whose roles, despite their differences, revolve around the same goal: the social and mental rehabilitation of inmates.