Les soins pénalement ordonnés (II). Mise en place d’un dispositif d’accueil de patients sous main de justice au sein d’un service de psychiatrie de secteur

RésuméL’article traite des soins pénalement ordonnés et des difficultés qui leur sont liées du point de vue des soignants. Il débute par une présentation du dispositif d’accueil des patients sous main de justice mis en place au sein d’un service de psychiatrie de secteur. Puis il se poursuit par un état des lieux des situations reçues au sein du service, en ambulatoire et plus rarement en hospitalisation. Il aborde ensuite, à partir de ces mêmes situations, les difficultés concrètes de l’articulation entre santé et justice lors de la mise en place de la prise en charge. Celles-ci tiennent notamment à des problèmes de compréhension des attentes du juge par les soignants. Enfin, deux situations cliniques viennent illustrer, pour l’une la manière dont le dispositif a permis d’engager un suivi, pour l’autre la manière dont, malgré le dispositif, un certain nombre de difficultés ont mis le soin en péril.

ObjectivesThe aim of this article is to describe a device to receive the condemned patients by criminal justice in psychiatry. It is also to expose the problems that we encounter in those specific cases.MethodFrom this device we discuss the difficulties that justice and care have working together. We present our device and an inventory of the situations that we have encountered in the hospital. During 2012, we received 26 cases of persons who were involved in the care of a legal restraint. Eighteen were concerned by an “obligation of care”, 7 came in order to “injunction of care” and one of them was in an alternative to legal prosecution. The acts for which they were convicted present a sexual nature for the majority, such as rape, sexual assault, the indecent exposure and the attempted corruption of minors (11 including 8 on minor). The rest were distributed as follows: Domestic violence aggravated by attempt to murder (4), theft associated with other crimes such as arson, drug trafficking and/or some acts of violence (6), pyromania (2), willful killing (1), and violence with weapon (1). For one of them, we cannot know what types of acts have been committed. One woman, who committed fires, was affected by these measures. All the others were adult men but four of them were minor when they committed their crimes or offenses. The duration of treat imposed ranged from 1 year to 10 years. Several difficulties arise in this type of support. The first concerns the relationship between justice and health. The first challenge for the therapist is to know in which configuration is the patient, obligation or injunction care. Another difficulty is then to understand what is expected by the court. These two problems are important for the therapist who has to inform and explain to the patient what is involved in the legal framework of the treatment. Another sort of problems appears in the care of those patients. There is discontinuity of care. This can be chronological but also concurrently. About the first, the chronological discontinuity, we observe that during his life in jail, the patient met with several therapists, because he has had to move regularly from one prison to another. After his release, he has to choose a new therapist. Those changes may also be related to the mobility of the professionals themselves. The second, the concomitant discontinuity, concerns patients who consult several therapists for various reasons (alcohol, mental illness, etc.), but everyone can work without knowing the others. To illustrate these difficulties, we conclude with the presentation of two clinical situations, two men who have committed acts of rape and sexual assault. They do not have the same psychopathological profile, but appear interesting to understand the importance of establishing a device to receive such situations to promote the implementation of the therapy. The first case concerns a young man convicted once for multiple rapes. It shows how the work on his personal question was the means to follow the treatment beyond the deadline imposed by the judge. The second concerns a young man repeatedly condemned for sexual assault and illustrates the difficulty of setting up the system and the failure of the therapy.ResultsUnderstand the laws and their application is not really easy for the therapist. But the implementation of the legislation is more complex. If we want to hope that therapy will be beneficial in this situation of the care for condemned persons, it seems very important to organize support for the patient and the therapist. It is also important that the therapist explains the protocol for the patient.