Of constraint and consent. Recomposing regulations in mental health practices – CONTRAST

In order to shed light on these concerns, which the social sciences literature does not adequately addresses, due to an excessive opposition between constraint and consent, the project CONTRAST focused on the regulations of care practices. The approach adopted is transversal to public policy’s categories and observes how the juridical, ethical, and deontological formalized rules, which value the principle of consent, are applied or not in situations. The project rests on the hypothesis that regulations are found not only in the jurisdictional formulation of this principle, but also in the ways professionals account for, or keep discreet, the forms of constraint their care practices involve. To test such a hypothesis, the project combined an original theoretical approach of regulations with an extended comparison of care practices in contrasted juridical and ethical contexts.

The constitution of a pluridisciplinary team, where sociologists, jurists and philosophers collaborate on the two axes of the scientific program as well as in the empirical tasks, allows for such an ambition.

Initially, the comparative axis studied five mental health practices (listening, hygiene, restraint, dealing with personal belongings, medication), in eight fieldwork sites offering contrasted contexts for exercising constraint (hospital units, community services…) and which are regulated through various rules (healthcare, medico-social, or social institutions). The epistemological axis aimed at specifying the concept of regulation, at the junction of stabilized and instituted rules, and of the heterogeneous use in the course of social life. Such a specification of the concept between the different theoretical and disciplinary traditions will reveal its value for understanding care practices.

The scientific program consisted in two joint empirical tasks. Task 1 led to the constitution of a corpus of jurisdictional texts elucidating the arrangement and hierarchy between the rules that locally apply to care practices. Task 2 established a corpus of cases coupling observations of situated care practices with discourses on their justification. Feasibility and coherence were ensured through the implementation of a common methodology in fieldwork sites previously researched by team members.

The pluridisciplinary analysis of the data led in task 3 to elaborate various analytical and reflexive reports, opening to multiple publications. The reports were discussed during the team seminar and scientific events, including international workshops and conferences. These events, along with numerous collective and individual publications, participated in disseminating research results, and in fostering and stimulating debates and collaborations, both in France and internationally. The Collectif Contrast website was a decisive tool in this process.

This type of regulation raises new questions about the current challenges faced by the democratization of care.

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In the past decades, the principle of consent has become increasingly present in the juridical, administrative, and ethical rules regulating professional care practices in the health and in the social domains. This evolution transforms the forms of constraint in care practices as well as the meaning of its use.
Particularly salient in mental health care, these reorganizations in the regulating frame of care practices affect both the jurisdictional instances (judiciary, professional, administrative, ethical) which officially produce and implement the principles, and the actors in situation which discreetly resolve the moral dilemmas they are confronted to. These changes also redefine the frontier between the practices that are valued and the ones that pertain to “dirty work”, thus raising important societal concerns regarding the balance between the civil concern for individual liberty and the more social concern for protection.
In order to shed light on these concerns, which the social sciences literature does not adequately addresses, due to an excessive opposition between constraint and consent, the project CONTRAST focuses on the regulations of care practices. The approach adopted is transversal to public policy’s categories and observes how the juridical, ethical, and deontological formalized rules, which value the principle of consent, are applied or not in situations. The project rests on the hypothesis that regulations are found not only in the jurisdictional formulation of this principle, but also in the ways professionals account for, or keep discreet, the forms of constraint their care practices involve. To test such a hypothesis, the project combines an original theoretical approach of regulations with an extended comparison of care practices in contrasted juridical and ethical contexts.
The constitution of a pluridisciplinary team, where sociologists, jurists and philosophers collaborate on the two axes of the scientific program as well as in the empirical tasks, allows for such an ambition.
The comparative axis studies five mental health practices (listening, hygiene, restraint, dealing with personal belongings, medication), in eight fieldwork sites offering contrasted contexts for exercising constraint (hospital units, community services…) and which are regulated through various rules (healthcare, medico-social, or social institutions). The epistemological axis aims at specifying the concept of regulation, at the junction of stabilized and instituted rules, and of the heterogeneous use in the course of social life. Such a specification of the concept between the different theoretical and disciplinary traditions will reveal its value for understanding care practices
The scientific program will first consist in two joint empirical tasks. Task 1 will lead to the constitution of a corpus of jurisdictional texts elucidating the arrangement and hierarchy between the rules that locally apply to care practices. Task 2 will establish a corpus of cases coupling observations of situated care practices with discourses on their justification. Feasibility and coherence are ensured through the implementation of a common methodology in fieldwork sites previously researched by team members.
The pluridisciplinary analysis of the data will lead in task 3 to elaborate various analytical and reflexive reports, opening to multiple publications. The reports will be discussed during the team seminar and scientific events (3 day-long seminars, 5 international workshops, 1 two-days conference). These events also participate in disseminating research results, and in fostering and stimulating debates and collaborations, both in France and internationally.