Measuring Mental Disorders: Psychiatry, Science and Society

By Philippe Le Moigne

This book is a collective work draws on the perspective of social sciences, mobilizing perspectives from the sociology of science, the history of psychiatry, medical ethnography and public policy analysis. This initiative, which has no precedent in social sciences, is surrounded by an original, if not apparently paradoxical statement: considering that the deployment of these processes, strictly formal and depersonalized, is justified in becoming the rule in a society known as "individuals".

• Presents the measurement of mental disorders (tests / scales) across the various sectors
• Determines the underpinning of this measure and its performance
• Explains the rise of these tests and its success
• Understands its impact on users

• Language: English
• Publisher: Elsevier Science
• Release date: Nov 21, 2018
• ISBN: 9780128172520

Book preview

Measuring Mental Disorders

Psychiatry, Science and Society

Philippe Le Moigne

Health Industrialization Set

coordinated by

Bruno Salgues

Edited by

Table of Contents

Cover image

Title page

Copyright

Introduction: Instruments and Subjects: Individuality and Its Rules

I.1 The institutionalization of mental health: the context of the emergence of assessment tools

I.2 The negotiated order of the DSM-III

I.3 The standard: a new format for rules?

Part 1: Basic Principles: Strengths and Limitationsof Psychiatric Assessment Tools

Introduction to Part 1

1: The Spread of Psychiatric Nosography into Science: Origins and Issues of the Research on Depression (1950–1985)

Abstract

1.1 First period: from the reactional model to the earliest clinical hypotheses (1950–1977)

1.2 Second period: growth and limits of brain neurochemistry (1978–1984)

1.3 Third period: toward principles of standardized clinical evaluation (from 1985 onwards)

1.4 Conclusion

2: The Hamilton Scale as an Analyzer for the Epistemological Difficulties in Research on Depression

Abstract

2.1 A measurement without an object to be measured

2.2 Multiple, but ineffectual, criticisms

2.3 Moving toward a paradigm crisis

2.4 Conclusion

Part 2: Developments: Chronicles of Successful Tests

Introduction to Part 2

3: A Golden Standard to Evaluate OCD: On the Use of the Y-BOCS

Abstract

3.1 The historical and ontological development of the scale and the disorder

3.2 An instrument of explicative and structuring objectification

3.3 Limits and evolution of the scale

3.4 Does the Y-BOCS have a (promising) future?

4: Objectifying Dementia: the Use of the Mini-Mental State Exam in Medical Research and Practice

Abstract

4.1 From success to controversy

4.2 A convertible capital

4.3 Conclusion

Part 3: Uses: the Tests in Context

Introduction to Part 3

5: The MMSE in Practice: the Medical Relationship Reflected through the Administration of a Neuropsychological Test

Abstract

5.1 The interpretation of the tests during the initial diagnosis: listening to and evaluating the companions

5.2 Testing cognitive function, working on relations with the families: the multiple uses of the test over the long-term in relations between carer, patient and families

5.3 Conclusion

6: From Care to Risk Prevention: the Success of Screening Tests for Drugs at the Workplace (United States/France)

Abstract

6.1 From the clinic to the Vietnam war: innovation and initial uses

6.2 Regularizing and standardizing: the European domestication of drug screening

6.3 Conclusion

Conclusion

List of Authors

Index

Copyright

First published 2018 in Great Britain and the United States by ISTE Press Ltd and Elsevier Ltd

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Notices

Knowledge and best practice in this field are constantly changing. As new research and experience broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary.

Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein. In using such information or methods they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility.

To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume any liability for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein.

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© ISTE Press Ltd 2018

The rights of Philippe Le Moigne to be identified as the author of this work has been asserted by him in accordance with the Copyright, Designs and Patents Act 1988.

British Library Cataloguing-in-Publication Data

A CIP record for this book is available from the British Library

Library of Congress Cataloging in Publication Data

A catalog record for this book is available from the Library of Congress

ISBN 978-1-78548-305-9

Printed and bound in the UK and US

Introduction: Instruments and Subjects: Individuality and Its Rules

Philippe Le Moigne

This objective of this book is to detail, through the lens of the social sciences, how and why the popularity of psychiatric measures has soared since 1980. This was when the first dedicated publication in the field – the Diagnostic and Statistical Manual of Mental Disorders – Third Edition (DSM-III) (APA, 1980) ¹ – was published. From this date onwards, the widespread use of the Manual has significantly transformed language and practices in the discipline (Pichot 1984), even though the measuring equipment that the DSM laid claim to dates back to the late 1950s. This was the period where psychotropic medication first appeared and it became a legal obligation to prove the efficacy of medication, in contrast to other treatments, especially psychoanalytic therapy (Healy 1999, Demazeux 2013a).

In the following discussion on the assessment tools, we first examine scales or tests, that is observation scales or questionnaires primarily meant for diagnosing patients, or again, used to measure changes as they undergo therapy. This book thus explores the understanding of the principles behind, and the use of, these scales, with the exception of the last chapter, which focuses on a biological test used for screening for drug use in the workplace. These scales may include multiple items with ratings or may be reduced to a list that summarizes some elements of observation, as in the case of the Mini Mental State Examination (MMSE), used when screening for Alzheimer’s disease (Brossard 2014, Béliard 2014, Béliard and Eideliman 2014), to which two chapters of this book are dedicated. Generally, each item on the scale is assigned a certain score either by the clinician, after consulting with the patient, or based on the patient’s responses to a questionnaire. Once this is done, the sum of the scores is then compared to a predefined threshold score in order to establish whether there is a clear-cut diagnosis. In cases where the evaluation is repeated over time, it can also be used to observe to what extent the patient’s condition has improved (or worsened) (Rush et al. 2008, Guelfi 1998).

Beyond these differences in form, it must be recognized that these scales or tests are, today, an obligatory step in research, so much so, in fact, that they keep increasing in number as the investigations into mental disorders have multiplied. Thus, these tests are applicable to the diagnosis of disorders such as depression, schizophrenia and personality disorders, as well as to the measure of how autonomous or functional a person with the disorder is, or again, to the definition of best practices in caring for patients. This expansion was not confined only to the science sector or professional practice: it spread to most areas of social life to such an extent that it has acquired a vehicular or matrix form.

Consequently, these instruments are also used for actuarial computations, reimbursement for care, hospital management, forensic expertise (Menninger and Nemiah 2000, Rush et al. 2008, Briffault 2010), and also (in line with a much older use, it is true) to study orientation in education, for army recruitment or corporate hiring processes (Buchanan 2002, Pâquet and Boivin 2007, Crespin 2009). They have also recently been used to estimate the quality of life or the well-being of an individual (Le Moigne 2010b). How do we explain the matrix style characteristic of these tools? And to what can it be attributed?

Taking a detour to look at how research work is organized may offer us an initial part of the response. If we remain within this sphere of activity, a clearly outdated vision of the role that these instruments play in research tends to attribute to them the status of a simple technical mediation between theoretical thought and its confrontation with fact. Seen in this light, the instrument is, at best, a useful tool for demonstrating a hypothesis. This rationalism remains, at the least, abstract and powerless when it comes to describing ongoing research, its organization of work and its historical development. As the sociology of science has shown us, one cannot imagine the expansion of this field of activity, starting from the 1960s, without the role played by the formalization and diffusion of generic tools in research (Shinn 2000, Shinn and Ragouet 2005, Le Moigne and Ragouet 2012). This is why we cannot reduce the use of these instruments to prove a conceptual idea. This instrument is itself based on practical reasoning, endowed with rationalizations and references unique to it, while always being more or less grounded, that is considered from the constraints and the feasibility of scientific activity and from the pragmatic experience of the researchers.

However, while these tools played an undeniable role in the sciences, this does not lead, a contrario, to the deduction of a positive or apologetic history of instrumentation. Such a development leads to placing the instrument in the crucible of objective science, a credo behind which the authors of the DSM-III did not hesitate to rally (Blashfield 1984, Sadler et al. 1994, Demazeux 2013a). The risk here was of overturning rationalist thought, as the necessity for empirical refutation through experiments in research and its instrumental equipment was then held to be primordial and decisive, while theoretical reflection was assumed to be ancillary. By extension, this reasoning could lead one to think that obtaining tangible and constant results, through the use of a measuring apparatus, was enough to carry out demonstrations. But demonstrations of what? With no explanation, no representation of the object and processes studied, a constant is devoid of any meaning ² .

And again, these discussions on principles do not justify the diversity in both the scientific nature of the research instruments as well as the audience addressed by the research instruments. In order to take this into account, a broader vision of the use of these instruments is needed. Thus, in certain cases, the instruments relate a virtuous process at the end of which the use of the tools born of the scientific activity seem to respond to a sort of evidence; their use has been approved by research, while they find numerous applications in society. For instance, the series of examples described by Terry Shinn of automatic control systems, ultracentrifuge systems, laser systems or, again, microprocessor systems (Shinn 2000). In other cases, the assessment tools may testify to the relations between opposing forces, its conceptual and factual pertinence may be debated (if not roundly criticized) without this disaccord resulting in its use being challenged either in research or in its applications in society. To summarize: in this example, the use of the instrument represents a form of compromise; this use is judged acceptable or even practical, without the form being completely approved. But how can we explain its continued use if it does not win adherents? Such a situation may be imagined into probability when we can distinguish the intrinsic quality of the tools from their organizational properties. In other words, it may be that certain tools continue to be employed despite the criticism leveled at their use, simply by virtue of the regulation and stabilizing effects they bring about. For example, if using this tool validates the position of the research sector that designed the instruments, of the professionals who keep turning to it, as well as of all or a large part of their clientele, then this is enough to maintain the distribution of these tools, even though there is no unanimous view as to their use. And thus, this specific case offers quite a good description of the status of measurements in the field of psychiatric research and activity.

There is more than one paradox here: despite the continued and exponential development in science, in medicine as well as among the population involved in the evaluation of mental disorders, the creation and also the use of these tests designed by psychiatry have always been criticized, and often quite rightly so (Briffault and Martin 2011), including, first and foremost, by those with a solid foundation of psychiatric knowledge underpinned by statistics and standardization (Blashfield 1984) ³ . How can we explain the endless generalization of a tool that has not been able to win adherents even among its producers, let alone from among its users? This is the paradox that, through various aspects, has taken on a sort of trademark form in psychiatry and which must be understood.

To shed light on this paradoxical development, we propose a short digression into the sociohistorical context of the United States in which these tools were developed under the banner of standardized evaluation. Through this prerequisite we will try to show how the rise of objectivity based on the instruments then led, in this context, to the rise of an equally radical subjectivism, attributed to the singularity and autonomy of the individual. This context, which can be best described as that of the institutionalization of mental health, placed psychiatric knowledge and the care of mental disorders before the dual problem of designation and regulation. This is why (and this is the argument we will be developing, further along) it is possible to consider that the use of the standardized scales and tests in psychiatry, through their assumptions, the form they took, or again, through their modes of validation, thus offered a response that was at least appropriate to this crisis situation. In other words, this kind of development cannot be understood without recalling that these tools originally sought to re-establish the discipline’s authority as a counterpoint to the criticism from anti-psychiatry, which was particularly sensitive to defending the patient and to highlighting the fact that this was a subject entitled to all rights. In this context, despite its disputable and disputed qualities, instrumental objectivity produced truly structuring effects in psychiatry as well as with respect to its different target population.

Thus, the structuring effect that was deduced from the standardized evaluation and from its growth is quite closely connected with the concomitant rise in critical thought around the individuality of a person. If we accept this idea, then we must also accept its logical extension, at least as a hypothesis, which is as follows: there probably exists a relation of affinity between psychiatric measurement and the type of rules that must be developed in a society that prioritizes the promotion of the individual. This introduction concludes with a detailed examination of this hypothesis (which is, to all appearances, a paradox). It will serve as a guiding thread throughout this book, each chapter offering, in a way, a chance to measure its heuristic value.

I.1 The institutionalization of mental health: the context of the emergence of assessment tools

In order to fully understand the term individuality, any discussion on the topic must make a brief conceptual digression. The use of this term aims, first of all, to rise above the connotations and approximations that are generally associated with individualism. Individuality, here, signifies a system of values and norms, which places the individual at the center of its considerations by attributing to the individual at least three key qualities: autonomy, (the ability to create one’s own norms) independence, (the ability to free oneself of the influence of another through the intermediary of one’s own capacity for action) and singularity (or subjectivity, which is the fact of possessing one’s own identity (or a Self)) (Le Moigne 2012) ⁴ . It is this last quality that the term individuality seeks to integrate, unlike studies on individualism, which do not always include this dimension. Moreover, this self-differentiation and personal singularity are inseparable from the promotion of the individual that so many sectors of social life carry out, beginning with the world of art or even the psychologies of the Self, which are dedicated to individual growth. Furthermore, to consider individuality as a normative system, that is, as a series of moral obligations, is to implicitly defend a relational and dynamic sociology, i.e. a point of view for whom the integration of the individual into the analysis is never causal nor explicative. The question here is that of considering the person from a relational dimension. The individual is considered in a reciprocal relation that unites them with their group and, beyond this, with the collective, but they are not at the origin of this relation. In other words, the relational perspective, in which we see a direct reference to Norbert Elias, makes it possible to remove from the analysis of a person any reference to a self that is substantial, self-determined (in short, real) and thus protects the analysis from any psychological naturalism (Elias 1991, Descombes 2004).

But, to consider individuality from the normative angle is also to take into account the constraints that this system imposes on action, and on decision in particular, where an individualist thought tends to accept that these problems are resolved at the outset. Above all, the problems posed by individuality, beyond the logical difficulties surrounding questions relative to individual autonomy and independence, are related to its share of subjectivism. This does not refer to a subjectivity of action; that is for example, as in the Weberian tradition, to the manner in which social context informs the individual’s interpretation and is, in turn, informed by this interpretation (Weber 1971). The subjectivism associated with individuality admits that in probability, each individual is capable of a particular and inalienable view of the world. This principle, however, immediately comes up against a difficulty: how, given such idiosyncratic points of view, can we decide on a common vision of facts and existence, without this vision immediately becoming arbitrary?

This problem of action is most marked in the debate around the individual themselves, and especially the feeling that they experience about themselves. Who better than the subject can state, with awareness, whether they feel affected, by what and why? In the context of this subjectivism, the individual is naturally the first, if not only, person capable of diagnosing themselves and the disposition of their thoughts. Thus, this doctrine finds it hard to imagine that a third party could abrogate this right to themselves and claim expertise in this domain, as is done by clinical psychiatry.

This is why the tensions and debates that mark the history of the discipline in the United States, between 1960 and 1980, assume such particular importance. These events contributed to the position that psychiatry occupied at the heart of social change. There are two reasons for this. The first is that they contributed to the challenging of the institutional form that prevailed until then: the asylum. At this time, it was not only the nature of internment that was challenged, but more broadly the social status of the madman and the madness also changed in nature (Grob 1994). This is why, through conflict and negotiations, American psychiatry then participated in the institutionalization of a new normal and pathological map, under the banner of mental health, and became the cradle of nosographic reform, which would then spread across the West (Le Moigne 2010a). In this way, it contributed to the spread of new definitions for health and, beyond this, promoted the growth of a new format of rules across the standardization of this nosography.

The standard that supported the production and propagation of this new representation of health was the now famous DSM-III, published in 1980. This Manual listed the diagnostic criteria for different mental disorders and, in the form of a decision tree, made it possible to establish whether an individual was or was not affected by one of these disorders. This was, therefore, a normalized repertory of mental disorders whose construction and use would prove to be, at the very least, formalized and impersonal. In a context that was increasingly open to the expression of, and the singularity of, individuals, the resounding success enjoyed by a Manual governed by the most formal objectification of mental disorders was thus quite surprising. In order to try and understand the origins of this apparent paradox, it may be useful to bring together two streams of information. First of all, as concerns the information on context, we can base ourselves on studies that sought to describe the historical configuration in which American psychiatry found itself, between 1960 and 1980. As a counterpoint to these, we can add a brief analysis of the content of psychiatric instrumentation, which developed toward the end of this period. Here, an introduction of the architecture of the DSM-III and its organization across 5 Axes will indeed prove to be useful (Le Moigne 2010a). Let us begin with an overview of the effects of this context before using a few salient examples to illustrate the new configurations of meanings that the DSM-III sought to diffuse.

I.1.1 Psychiatry confronted with psychologies of the Self

The tensions that affected American psychiatry in the 1960s and 1970s sometimes were due to a theoretical opposition between biology and psychoanalysis (Shorter 1997) and, where applicable, to the rivalry between the psychiatric and psychological professions. Another explanation consists of placing these tensions at the heart of a larger social debate. Indeed, if psychiatry took center stage in these debates, it was not entirely an accident: its diagnosis contained a designation of the pathology and by extension, designated normality which, in the American context in the 1960s, ended up acquiring the aspect of a generic dimension and challenge. More precisely, this period was marked by the rise in power of the psychology of the Self, both among academics and laypersons, which called for a transformation of a society, adhering, largely, to the principles of a new characterization of pathos and psychic normality (Le Moigne 2014).

This characterization was not new: in fact, the psychology of the Self, which spread far and wide in the 1960s, had a long history. As was convincingly demonstrated in the works of Eugene Taylor, it is to William James, in fact (the father of American psychology) that we owe one of the first formalizations of this psychology of the Self, proposed toward the end of the 19th Century (Taylor 1992, 1996, Le Moigne 2014). In line with Jamesian thought, the philosophy of Self informed American personality psychology in the interwar years through figures such as Gordon Allport and Henry Murray. It reached its apogee in the success that the humanist current enjoyed in the post-war years, under the banner of person-centered psychology and developmental psychology promoted by Carl Rogers and Abraham Maslow (Taylor 1991). But in the 1960s and 1970s, this psychology spread well beyond academic circles. It sharpened the demands of the ex-patient movements, for individual liberties and civil rights, and it promoted the deinstitutionalization movement and the fight against the stigma attached to psychiatry.

Thus, to understand the dynamics of this grassroots movement, one must first understand the needs that the psychology of the Self strove to meet, whether academic, professional or activist. What are the principles underlying this, if we can, indeed, reveal a unity in this psychology beyond its diversity of approaches and manifestations? And, most especially, what are the action problems that this psychology of the Self poses to psychiatry? And how does psychiatry square its principles with this orientation?

The psychology of the Self holds that the individual’s autonomy is inalienable and produced in full awareness. This perspective, thus, immediately associates personal action and the definition of self with action that is self-determined as well as mental and internal. Thus, mental health and individual emancipation here go together. Nonetheless, this psychology does not overlook psychopathology. It finds that any mental disorder is inimical to free will and individual determination, and thus embodies the antithesis to the principles it holds most dear.

However, given the inalienable character of personal consciousness, it remains that this school of thought does not think of mental disorders as completely annihilating individual expression. This is why this subjectivism condemned psychiatric diagnosis if this designation reduces the patient to an aberrant being, whether the diagnosis dictated the person must be set apart in an asylum or, as would increasingly be the case from the 1960s onwards, when this designation aligned itself with biomedicine and its physiological underpinnings. According to this philosophy, mental illness as conceived from a biological or unconscious etiology, that is, as a phenomenon that acts unbeknownst to the individual, does not exist. The pathos, constructed here away from psychobiology as well as psychoanalysis, is always relative: mental disorders only have meaning when related to the particularities in the psyche of each individual and, as a subconscious or co-conscious state it always remains accessible, in probability, to the consciousness of the person affected ⁵ .

With the consequences of mental pathology being relativized, psychic troubles thus arrived at a certain normality (Le Moigne 2005). Yet, if the jurisdiction of normality was thus called upon to grow larger, it was itself relativized. Why? Because in the context of this philosophy of the Self, normality is also assessed in terms of individual expression. Thus, whether a mental expression is functional, acceptable or well-adapted (in short normal) is not enough to prove an accomplished personal development: in order for this expression to be judged healthy and authentic, it must also be associated with actions and thoughts that can be attributed to the concerned person. Personal growth, self-actualization and the liberation of an inner potential are all perceived here to be the condition of complete individuality and, by extension, that of complete and whole mental health ⁶ . On the contrary, an incompleteness of self or low self-esteem is likened to a cause of distress or, in some cases, an entire morbidity requiring psychotherapeutic, or even medical care ⁷ .

From this double process of reshaping pathology and normality emerged a program, which was contradictory to say the least. In the first case, with the incapacity of the person afflicted with the mental disorder being relativized, the mental disorder lost a part of its aberrant character, at the risk of drastically reducing its treatment. In the second case, managing personal development tended, on the contrary, to confer onto the mental disorder (under the aegis of the lack of self-fulfillment), the status of a particularly widespread malaise.

Two implications can be deduced from this contradiction. (1) First of all, a part of the argument promoted a reduction in health care, notably in its institutional form, while another part of the argument proposed (in unconditional support of self-actualization) an unlimited expansion of the care offered though without clearly specifying whether the expertise here was accorded to psychiatrists, psychologists or again to self-help groups. (2) The psychology of the Self then paves the way for a form of confusion between mental pathology and affliction, so much so that mental disorders appear to be both everywhere and nowhere and finally become indefinable. This indecision is at the heart of processes that, more or less paradoxically, led to a decline in clinical psychiatry, before boosting the discipline’s return to authority in the field of diagnosis.

I.1.2 The two sides of deinstitutionalization: health at the risk of illness

In 1963, the United States Congress voted in the Community Mental Health Act that led to considerable deinstitutionalization (Grob 1995, Menninger and Nemiah 2000). This law made it possible to end the construction of asylums and to limit the role played by psychiatric hospitals managed by the federal government in caring for chronic illnesses. The creating of Community Mental Health Centers (CMHC), which were overseen by the States, sought, instead, to welcome patients into an open setting, promoting their social integration. The legislation had considerable impact: between 1955 and 1988, the number of patients admitted into psychiatric hospitals fell by nearly 80%, while the annual volume of therapeutic actions saw a fivefold increase (Grob 1994). This contrasting evolution testifies to the rise in hospitalization in the private sector and the growth of local structures. In other words, in essence the development of care-giving and community structures, in particular, were most beneficial in minor pathologies. But for the large majority of psychotic patients with no resources, deinstitutionalization resulted in their being deprived of health care. The chronic overcrowding in public hospitals and the invention of psychotropic medication contributed a great deal to the reduction of policies of internment. But this was also in response to the movement of ex-patients fighting for civil rights, which was associated with the antipsychiatry of the 1960s.

For the most radical of these movements, such as the psychiatric survivors movement, mental disorders did not exist. This belief was so deeply held that they refused pharmaceutical treatment and contested the legitimacy of the psychiatric profession. This group opted to promote alternative care, organized outside the medical system and its movement finally died out in the early 1990s, due to a lack of funds. On the other hand, some organizations were able to carry out a similarly radical criticism of psychiatry but in the name of mental illness. To understand this principle, we must go back to the post-war context and the new legitimacy it offered to environmental approaches to psychic disorders. The rise in war psychoneuroses among soldiers (in Kardiner’s words, 1941) seemed to corroborate the hypotheses developed, within the framework of mental hygiene, during the 1929 crisis. According to this vision, any individual confronted with intense life events may in probability develop a mental disorder (Pols 2001). This perspective made it necessary to conceive of psychic trouble in terms of a shared vulnerability. This presaged a large extension of the health policy, especially as certain movements of the 1960s, in line with mental hygiene, petitioned for the introduction of prophylactic action in this field. This perspective affirmed the necessity of treating healthy subjects by preventing the trauma that they were liable to undergo through their social life. In this sense, the movement considered that internment in an asylum offered patients artificial protection against life circumstances that were at the origin of their disorder and declared itself in favor of a policy in the real world.

These movements, whether they fought for patients or for the prevention of the pathology, all promoted deinstitutionalization. Nonetheless, in the first case, the patient’s right to autonomy called for an explicit rejection of the disorder and its medicalization, at the risk of then implicitly reducing care. In the second case, the illness seems, on the contrary, to act as a lever in the recognition and protection of the individual against threats from social life, at the risk of leading to a particularly inflationary policy ⁸ .

This new context widened the spectrum of the complaint within the field of malaise, but it complicated its reception and eligibility to the extent that its diagnosis could no longer be entrusted only to the therapist’s point of view. In fact, the question of personal suffering first required a diagnosis by the individual. It was the individual who was assumed to be able to judge this best. This did, of course, have a direct impact on the authority of psychiatry and its clinical practice. Further, in a context of Selves, the question of who, with minimal consensus, could define the contours of pathology and mental health remained completely open.

I.1.3 An indefinable pathology: the peak and decline of clinical psychiatry

After the Second World War, the response to the topic of mental health marked a new demand for care, which quite quickly placed psychotherapy at the heart of psychiatric