Résumé Dans quelle mesure peut-on parler, aujourd'hui, de ‘nouveaux concepts’ dans le champ de la santé mantale? Depuis le Mental Hygiene Movement, l'apport de la psychanalyse, celui de la Preventive Psychiatry, les déclarations ne manquent pas, qui visent à dépasser le ‘schéma de réparation’ (Goffman) de la médecine classique, et de faire de la santé—comme le disait dj́á William A. White dès 1930—‘un concept positif’. Ces transformations importantes dans les conceptions de la santé mentale ont-elles réssui à s'imposer dans les pratiques? On a choisi ici de privilégier ce point de vue de l'application (ou de la non application) des “nouveaux concepts”, plutôt que de s'en tenir aux textes théoriques où ils ont émergé, ou aux déclarations d'intention qui proclament leurs mérites. Sont d'abord analysés dans cette perspective, les effets des principales politiques officielles de réforme moderne de la médecine mentale: mouvement des Community Mental Health Centers aux Etats-Unis, ‘politique de secteur” en France, programmes préventifs de dépistage systématique des risques. Ces réalisations ont considérablement élargi et assoupli les conditions d'exercise du schéma médical en psychiatrie. Mais elles sont restées en-deça de la volonté de promouvoir une approche totalement nouvelle de la santé mantale qui l'inscrirait résolument dans un modéle de croissance, et non plus seulement de restauration ou de conservation. A côte de ces organisations officielles du système de santé, se sont développées des initiatives plus marginales, mais dont on peut se demander si elles n'ont pas réalisé des avancées plus nouvelles. Ainsi, dans la postérité de la psychanalyse, le courant de la ‘therapie pout les normaux’, ou les tentatives de réappropriation de la dimension sociale dans la dynamique personelle, nées des critiques socio-politiques de la psychiatrie. Cependant, si elles paraissent souvent plus innovantes, ces orientations demeurent également fragiles dans leurs implantations et ambigües dans leurs réalisations. Mettre en oeuvre de ‘nouveaux concepts’ de la santé mentale constitue ainsi, dans une grande mesure, une tâche d'avenir, dont on a seulement tenté ici de dessiner les principales voies, en insistant surtout sur les difficultés rencontrées pour les parcourir.
Abstract To what extent can one speak to-day of new concepts in the mental health field? There have existed for a long-time (since, for example, the Mental Hygiene Movement and the tendency Preventive Psychiatry in the United States) new programmes for the administration of care which aim at going beyond the ‘repair model’ (Goffman) of classical psychological medicine, and at developing a ‘positive concept’ of health (after William A. White in 1930). In the same spirit, psychoanalysis has promoted a dynamic concept of psychic disturbance which transcends the static opposition of health and illness Finally, the insistence on systematic prevention of risks also follows the tendency to transcend the medical relationship. Thus, the conditions for bringing about, conserving and developing mental health have long ceased to be susceptible to thinking out from the base of clinical psychiatric concepts. These important transformations in the conceptions of mental health do not, however, guarantee their establishment in practice. We have chosen to emphasize here the point of view of the application (or non-application) of ‘new concepts’ in affective policies, rather dealing only with the theoretical text from which they have emerged, or declarations of intention that proclaim their merits. (1) This article attempts firstly an evaluation of the reform movements that have developed since the end of the Second World War, mainly in the United States and in France with the following question as point of departure: “To what extent have modern mental health policies been innovative in relation to classical psychiatry dominated by a medical conception of mental health, that is to say a model that is “repair-oriented” or curative rather than positive or preventive”? Firstly, the achievements of the Community Health Centres in the United States and the Policy of the Sector (politique de secteur) in France is analysed. In both cases the ‘theoretical’ programmes of the promoters are compared to that which has been accomplished in fact. What, concretely, has happened to the will to “enlarge the conception of mental health to include concepts that no longer include mental disorder”, as proclaimed by Leonard J. Duhl in summing up the spirit of the Community Mental Health Centres and Retardation Act? The article attempts this evaluation on a three-fold level: new theoretical models envisaged, new forms of intervention put into practice and the institutional transformations that have been introduced during the last 30 years. The undoubted innovations so produced have enriched the range of intervention techniques, diversified and rendered more supple institutional procedures and displaced management approaches towards the community. Likewise, preventive policies and the screening of risks have lead to replacement of an individual clinical perspective by a more ambitious epidemiological or statistical perspective. Nevertheless we are still dealing for the most part with a more suple medical approach, specialized institutions and the intervention of health-care professionals. Essentially it is still a matter of dispensing care and avoiding illness (or risk factors). If theory concentrates on the positive aspects of health, practice adopts a defensive attitude in relation to disease and risk. Without under-estimating the importance of these recent transformations, it appears to be the case that the effective implementation of official mental health policies has stopped short of realizing the aspiration to develop a radically new approach to mental health that would be integrated into a growth model. (2) Alongside this official organization of a public mental health system there exist, however, certain, initiatives, more marginal, which have perhaps achieved more original advances. Two of these areas of practice are examined in this article: In the aftermath of psychoanalysis one notes the development of approaches which aim less at curing and more at developing personal potential (the human potential movement, bio-energy, Gestalt therapy, etc.). Psychic health is no longer a state which has to be restored or conserved, but is rather a project, a task that has to be undertaken without any end point. The ‘therapies for the normal’ employ techniques and exercises that have no residual medical sense to promote this idea of a type of health which is cultivated and intensified, which is, that is to say, integrated into a growth model, and which is no longer repair-oriented or curative. Certain movements critical of psychological medicine which developed toward the end of the sixties were not satisfied with denouncing the lacunae of the classical psychiatric approach. They attempted a reappropriation of the social dimension in personal dynamics. The ‘social’ is no longer merely an external norm of conformity to which one adapts, nor the riskladen environment against which one has to fortify oneself according to a defensive conception of prevention. The integration and the mastery of the environment defines health as a global condition, the synthesis of an harmonious personal, relational and social development. If these orientations appear to be innovating in relation to classical health conceptions, they remain fragile as regards their implementation and ambiguous as regards that to which they lead. The ‘work one oneself’ of the post-psychoanalytic currents risk leading to a self-satisfied narcissism of his own subjectivity. The active appropriation by the individual of his own life-context risks being a pious wish unless precise programmes and efficacious techniques support the project. Putting new mental health concepts into practice remains in large measure a task for the future and we have tried here simply to sketch in the principal pathways, underlining above all the difficulties encountered in proceeding along them.