Public Managers without Public Workers: The Tepid Origins of Sectorization

At the close of the Second World War, both public psychiatric managers and workers had the legal right to organize. Represented by the Syndicat, managers had begun to develop an independent political voice on matters of mental health policy. The Communist-affiliated General Confederation of Labor (Confédération générale du travail, or CGT) and its more independent offshoot, Workers’ Force (Force ouvrière, hereafter FO), had begun to organize workers in mental hospitals as well (Bouhallier Reference Bouhallier2021). But because outpatient services were limited at this time, worker organization remained more limited in that setting, too. As a result, a formal coalition between managers and workers on outpatient public mental health services had not yet formed, and this weakened the overall support for expanding and rebuilding psychiatric care after the war.

The relative novelty of the Syndicat, which had only just formed in 1946, also weakened the organization on several fronts. By the late 1940s, a rival group – the Trade Union of Nervous System Psychiatrists (Syndicat des médecins français spécialistes du système nerveux) – had formed to represent private practitioners and neurologists. Moreover, its members voted to affiliate with the Confederation of French Medical Trade Unions (Confédération des syndicats médicaux français, or CSMF), France’s powerful medical association that also favored private practice. These private practitioners jockeyed for attention from the Ministry of Health and Social Affairs (hereafter the Ministry), which in turn offered them spots on its advisory councils. In 1949, the Ministry even appointed the founder of the Trade Union of Nervous System Psychiatrists, Dr. Georges Heuyer, as the president of the reformed “Commission on Mental Health” (hereafter the Commission), a consultation body that had until then been reserved for public psychiatrists (“Séance du 24 mai 1949” in AN 19950173/1, 2). In the words of one prominent public psychiatrist, Dr. Georges Daumezon, the move rendered relations between his Syndicat and the Ministry “practically broken” (cited in Ayme Reference Ayme1995, 41).

The Administrative Circular of 1960 Makes Funds Available, If Indirectly, for New Mental Health “Sectors”

Nearly a decade passed without much policy change in public mental health until a personnel change at the Ministry opened a window of opportunity for the Syndicat. A group of bureaucrats sympathetic to the expansion of public mental health services appointed one of its leading members, Dr. Hubert Mignot, as “Technical Counselor” to the Ministry’s Bureau of Psychiatry. Dr. Mignot used the opportunity to promote the Syndicat’s vision for mental health reform, a concept called “sectorization” that had first appeared in a memo released by the Syndicat in 1947 (Ayme Reference Ayme1995, 51–52; Henckes Reference Henckes2007, 786). Over the following years, the proposals in this 1947 memo had filtered into the Ministry through reports written by members of the Syndicat sitting on the Commission.Footnote ²

The Commission’s 1955 report on psychiatric hospitals, for example, is particularly illustrative. In the report, the authors advocated for the expansion of government-financed mental health care services (especially outpatient services).Footnote ³ They argued that this expansion would equitably distribute mental health services across the territory, a policy frame that Lynch (Reference Lynch2020) has shown to be especially potent in France. Drawing on these ideas, the bureaucrats of the Ministry’s Bureau of Psychiatry drafted an administrative circular with suggestions for local officials on how to develop their public mental health system. Local authorities were to take stock of their psychiatric resources and design a program in line with the Ministry’s new mental health policy vision set out in the circular. With the intention of “separating the patient from his family and his environment as little as possible,” a team of mental health professionals would care for the needs of a catchment area of about 67,000 persons.Footnote ⁴ Each of the French départements (subnational units) would constitute an overarching “sector,” which would coordinate these teams and their catchment areas (“subsectors,” sous-secteurs).Footnote ⁵ It would be up to the chief psychiatrist for each sector, in conjunction with the director of the local health office, to determine the specific arrangement of services, in accordance, the Ministry presupposed, with population needs (1960 circular, 9). Those départements that lacked a chief psychiatrist (a not infrequent occurrence) would assign that task to another official, namely the département’s health director.

The 1960 administrative circular recommended, but did not require, that each sector include several types of services. Although expanding hospital capacity was at the top of the list (French officials were painfully embarrassed that the supply of beds in their country lagged far behind the World Health Organization standard at the time),Footnote ⁶ the authors of the French circular also recommended establishing services in each sector that resembled those promoted by their American counterparts advocating community mental health: an outpatient mental hygiene center, preferably integrated into a community center that served other social needs (centre polyvalent); a day hospital (a service directly inspired by the United States and other countries); a rehabilitation center; and a protected employment workshop.

Moreover, the circular remained agnostic as to whether these services should be public or private, perhaps a response to the protests of private and academic neuropsychiatrists, who disliked its approach.Footnote ⁷ In fact, the circular implied that nonprofit organizations would jump at the opportunity to enter this newly created market: “Day hospitals, re-habilitation centers, protected employment workshops are projects that above all will interest private, not-for-profit organizations, acting in conjunction with mental hygiene physicians at psychiatric hospitals.” Nonetheless, the circular continued, “nothing prevents interested local public authorities from pursuing such projects themselves” (1960 circular, 8). Moreover, the circular envisioned the sector as a sort of private–public partnership, whereby private clinical psychiatrists and neuropsychiatrists based in universities could “harmonize” their services with public and not-for-profit actors (11–12).

How did this simple, unbinding document jump-start the first feedback loop and eventually gain mythical status as the founding document of contemporary French mental health policy? Part of the answer lies in its obscure funding source. To support the implementation of its proposals, especially the non-hospital services, the Ministry suggested that actors draw on the public monies made available by the Decree of May 20, 1955 (1960 circular, 1). This earlier document expanded the availability of central government funds for mental hygiene dispensaries from a mere 20 percent to a whopping 80 percent of operational costs, extending the mandate of another policy produced in 1954.Footnote ⁸ Following the enactment of a law targeting the treatment of alcoholism, the Ministry had developed the dispensary program to tend to the unwelcome disruptions of various “social ills” (fléaux sociaux). Indeed, much of the Ministry’s initial attention given to mental health was motivated by the special case of alcoholism, but it soon expanded the definition of “social ills” to encompass many other conditions treated in psychiatric hospitals, such as psychosis.Footnote ⁹ Several addendum documents also released in 1955 made it clear that the funds could serve multiple purposes.Footnote ¹⁰

Limited Feedback and the “Long Sleep” of French Mental Health Services

Yet the funds allocated by the 1955 decree – though generous and relatively unconstrained during the booming Trente Glorieuses (1945–75) – would not be tapped to implement the 1960 circular for over a decade. Indeed, few sectors were established in the 1960s (Benamouzig Reference Benamouzig2005, 103; Coffin Reference Coffin, Gijswijt-Hofstra, Oosterhuis, Vijselaar and Freeman2005, 238). A needs assessment produced in the following decade noted that fewer than half of the anticipated sectors and their associated administrative infrastructure had been developed.Footnote ¹¹ Some analysts have even referred to this period as the “long sleep” of French mental health services (Murard and Fourquet Reference Murard and Fourquet1975, 195). Looking back on this period, the policy-maker Jean-François Bauduret lamented that “public psychiatry has lost [more than a decade] and has passed up a historic opportunity to rapidly reform itself thanks to a favorable economic context and a flexible and effective financial mechanism” (Bauduret Reference Bauduret2002, 2).

The political dynamics of the first feedback loop explain this delay. Although public managers conceptualized sectorization and secured some financial resources for it, the public mental health workforce in non-hospital services remained too small in the 1960s to exert significant pressure on government to increase expenditures on the sectors. Note that hospital workers did mobilize to protect their employment in the period immediately following the Second World War. Bouhallier (Reference Bouhallier2021), for example, shows how the CGT and FO unions representing employees of psychiatric hospitals in the Seine département resisted closures by setting up “defense committees.” Moreover, he finds that the support of public psychiatrists for the unions’ efforts “undoubtedly influenced” policy-makers, who ultimately conceded. But, for the most part, hospital workers in this period were demanding support from more established funding streams, such as Social Security (see Table 5.1). Employment in the non-hospital sectorized services remained too small to generate robust demand for funds in those alternative settings. It was not until the second feedback loop that the number of workers in outpatient services grew, putting pressure on managers and the Ministry to use the funds made available in 1955 and expand the sectors as suggested by the 1960 circular.

Table 5.1Timeline of psychiatric sector financing in France, key dates

Note: DDASS = Direction départementale des affaires sanitaires et sociales.

Until then, the 1960 circular remained a marginal document. Many reformers would have preferred a more substantial commitment to public psychiatry from government, perhaps made via order, decree, or even legislation. Instead, they received an unpublished set of guidelines, with some suggested, but undelivered, funds from the 1955 decree. Those funds would prove to be crucial to the expansion of public mental health services. In some ways, the (unintended) founding document of French sectorization is not the Circular of May 15, 1960, but the Decree of May 20, 1955, because of its attached funding resources. Nevertheless, over the following decade neither document was of immediate consequence.

1968 Aligns Public Psychiatric Workers and Managers

The 1968 Agreements Expand the Public Mental Health Workforce

It would not be long before the Syndicat’s participation in the strike began to yield concessions, the first of which was a new university degree that would significantly expand the mental health workforce. To appease students’ requests, legislators enacted a major reform of the university system in November 1968. In December, Education Minister Edgar Faure ordered the creation of a separate CES in psychiatry. This, however, was not enough for the protestors. The prestige of this new CES relative to the status quo was unclear, and no efforts had been made to accommodate psychiatric nurses’ demands for their own CES. The strike continued. It was not until May 1969 that the CES for sectorized psychiatric nurses (ISPs) was granted, nor until September of that year that the government strengthened, via decree, the CES for psychiatric physicians.Footnote ¹⁷

These new degrees would boost the pipeline of incoming mental health psychiatrists and nurses. The prestige of the new CES remained a significant sticking point. A clause in the decree allowed the universitaires to teach in psychiatric hospitals. “It is this last clause that has enraged psychiatric hospital physicians, who had become leery after the many years of domination of their discipline by CHU neuropsychiatrists,” reported a 1969 article in Combat, a leftist newspaper.Footnote ¹⁸

Underlying what Health Minister Robert Boulin called a “doctrinal and emotional” conflict was, of course, an awareness of how these initiatives would impact employment trends.Footnote ¹⁹ Under the current (1958) law, psychiatrists with research and teaching aspirations had two employment options: the CHU, which gave them access to lucrative privately paying patients, or the public psychiatric hospital, where patients were far less affluent and thus these psychiatrists were largely restricted to their salary. The clause in conflict could incentivize psychiatrists to have it both ways (accept private payment in CHUs and teach in public psychiatric hospitals), with the effect of depleting psychiatric hospitals of full-time doctors. To express their opposition to the continued “parachuting” of the university physicians out of public psychiatric hospitals, the Syndicat prolonged the strike.Footnote ²⁰

By November 1969, the government had had enough. In a press conference, Health Minister Boulin announced a second concession. To end the strike and resolve the conflict, he would reestablish the Commission on Mental Illnesses, which had been disbanded in 1964. With painstaking attention to maintaining a balance of power, bureaucrats in the Ministry sought to appoint representatives on each side of this public/private dispute. The nomination of the president presented a particular challenge: “It has been customary,” the Director General of Public Health, Pierre Boulenger, wrote to Boulin, “that the President alternate between a university physician and a hospital physician.” Weighing different options, Boulenger opted to appoint the well-liked hospital psychiatrist Dr. Henri Ey to the presidency and appointed Professor Théophile Kammerer to the vice presidency.Footnote ²¹

The decision to appoint Henri Ey, “despite his age,” to preside over the Commission reveals the desperation of the Ministry. Now in retirement, Dr. Ey’s age should have prevented his involvement in government affairs (he was four years past the age limit for public service). Moreover, his ill health made it more difficult for him to participate. But Ey was a unifying figure; once a president of the Syndicat, Ey had maintained an active neurological research portfolio during his career. The appointment of Professor Kammerer, a university psychiatrist with strong ties to the private sector, as his deputy would help to assuage any concerns regarding Ey’s lingering loyalty to the Syndicat, of which he was once president (Garrabé Reference Garrabé2005).

Although the appointments of Ey and Kammerer would smooth some tensions over the leadership of the Commission, the question of its membership was just as contentious. Particularly “delicate,” as Boulenger put it, was the question of representation by members of the Syndicat.Footnote ²² Although Boulenger favored the participation of both para-medical staff (social workers, psychologists, nurses) and nonmedical staff (national public servants, hospital administrators), he worried that “if one admits them all, high-level debates would become but quarrels of influence.”Footnote ²³ He suggested, then, extending ex officio (à titre de droit) appointments only to select members, while those with a “special competence in mental hygiene” would be appointed in merely “a personal capacity” (à titre personnel). Later that year, the Ministry published an order nominating 44 members to the new Commission, nearly all of whom (41) were appointed in this less formal capacity. Only those organizations who had played a prominent role in the former commission were offered ex officio status: the National Committee for the Prevention of Alcoholism (Comité nationale de défense contre l’alcoolisme), the Autonomous Trade Union of Social Workers in Departmental Services (Syndicat national autonome des assistants sociaux des services départementaux), and the Trade Union of Psychiatric Hospital Physicians (Syndicat des médecins des hôpitaux psychiatriques).Footnote ²⁴ The strike ended shortly after this announcement.

Even then, the effects of the Syndicat’s mobilization carried into the following year. In 1970, legislators finally enacted a third concession: the Second Debré Reform.Footnote ²⁵ By formally splitting public and private hospitals, it forbade all public, salaried physicians from accepting privately paying patients. The public designation was extended to psychiatric hospitals, but in order to preserve the “specificity” promised to psychiatric doctors and nurses, a separate hospital category was created: the Specialized Hospital Center (Centre Hospitalier Spécialisé, or CHS).Footnote ²⁶ To accommodate the projected growth in the workforce, the positions of assistant and adjunct CHS physicians were added (Leguay Reference Leguay2002, 11; Ayme Reference Ayme1995). This new designation gave mental hospitals significantly more authority over staff training and the distribution of financial resources. This latitude would make it easier for psychiatric hospital administrators to expand sectorized employment, and therefore services, in the coming decade.Footnote ²⁷

Positive Feedback Continues to Expand the Mental Health Workforce and Sectors

The effects of the 1968 protests and the resulting empowerment of mental health workers were evident at both national and local levels. Consider the Syndicat’s strategic use of the Commission on Mental Illnesses to rewrite the terms of sectorization in favor of public mental health workers, exemplifying their use of the “brokerage” mechanism. Following the workforce expansions just initiated (and additional agitation by the hospital psychiatrists, who launched a second strike between May and October 1971), the Commission turned to other mental health policy issues by organizing seven different thematic working groups. One group devoted itself entirely to sectorization, another to personnel (AN 19910084/28 and 29). Now that the Syndicat had ensured that few private or university psychiatrists would serve on these subcommissions, their public hospital representatives redesigned the Ministry’s objectives for the sector. With the help of the Commission, the Ministry released several new documents. The most authoritative was the Order of March 14, 1972, which now required départements to participate in sectorization. It was followed by a circular on adult psychiatry that reminded local authorities of the central government funds available (from the May 1955 “social ills” decree) to support the policy.Footnote ²⁸

Most importantly, these documents signaled a shift in tone emblematic of this policy feedback loop. The new circular differed from its predecessor in that it emphasized staff – not buildings – as the core resource of sectorized psychiatry: “Each sector is entrusted to a chief psychiatrist, responsible for a team of doctors, social workers, psychologists, nurses, etc.” (emphasis in the original).Footnote ²⁹ Moreover, the document’s annex, “Guidelines Concerning the Sector Team,” included an expansive list of professions that should be included in the sector teams: physicians, nurses, social workers, psychologists, even teachers and rehabilitative therapists. This interdisciplinary team would be necessary to “multiply” outpatient services. Département-level and hospital administrators were invited to draft a timetable to prepare for the “essential” (indispensables) appointments.Footnote ³⁰ Over the next two years, a flurry of additional documents and guidelines followed, the last of which concluded that “the years 1972–1973 represented an important stage in the development of French mental health policy.”Footnote ³¹

Throughout the 1970s, medical employment exploded, particularly in psychiatry. As more psychiatrists gained the new CES and began new positions as adjunct or assistant CHS physicians, they contributed to a ballooning of the number of medical staff at psychiatric hospitals. While the number of psychiatrists in France had hovered around 1,000 in the 1950s, by the 1970s their numbers had reached 13,000 (Cléry-Melin Reference Cléry-Melin2002, 796). Similarly, the new CES in sectorized nursing generated a steady pipeline of new staff into the growing sectors, as well as of allied mental health providers such as social workers.

As the number of medical degrees and positions proliferated, so too did the trade unions that represented them. The communist union CGT had close ties to public psychiatry through the Syndicat; in its earliest years, many members had been sympathetic to the Communist Party. However, upon its creation in 1964, a union with closer ties to the Socialists, the CFDT, garnered broad appeal among public sector workers, too. Workers who preferred the CGT but rejected the influence of the Communist Party in it, sought representation from the union’s offshoot: FO. Unaffiliated trade unions also sprouted during this period. These included the unconventional Trade Union of Psychiatry (Syndicat de la psychiatrie), in which medical professionals advocated “for psychiatry, not psychiatrists” (USP 2021). Motivated to win higher wages, obtain stronger employment protections, and expand their ranks, these trade unions pressured hospital psychiatrists and local administrators to take advantage of sectorization. The availability of the generous May 1955 “social ills” funds – not yet affected by the emerging oil crisis – made it easy to satisfy these pressures. The long-ignored funding mechanism now became central to the maintenance of expanded mental health services (Bauduret Reference Bauduret2002).

The national policy changes of this time period were most vividly experienced at the local level. In fact, studies documenting how mental health workers advocated for the expansion of sectorization in individual départements has become a rich area of research in recent years.Footnote ³² In his study of CGT activists at Le Vinatier hospital and sector in Rhône, Alfandari uncovers a wealth of archival evidence showing how workers advocated for funding increases, staffing diversification and expansion, and secure training and employment schemes in the wake of the post-1968 policy changes. Protecting the sector’s public status was also crucial to workers: A joint CGT–CFDT leaflet of 1973 empathically decried “NON” to a proposal that would allow private sector organizations to manage some or all sectorized services (reproduced in Alfandari Reference Alfandari2017, 91). These efforts are what prompted the local union’s then general secretary to claim “‘it’s thanks to the CGT’ that the sector now exists” in an interview years later (quoted in Alfandari Reference Alfandari2017, 90).

Local public managers were responsive to such protests, and here, too, acted as brokers between workers and policy-makers. In his study of sectorization in Angers, Vincent Guérin (Reference Guérin2011) offers an example that illustrates how public managers took advantage of the generous “social ills” funds to placate their expanding staff. In January 1972, the personnel of the public psychiatric hospital in Sainte-Gemmes-sur-Loire went on strike. The group of protestors, composed mostly of nurses, sought to expand their workforce. In a coauthored report, the département’s seven chief psychiatrists (one for each sector) offered their support of the strike, denouncing the fact that it took two protest movements (the first in 1968 and now this one in 1972) to persuade authorities to hire more personnel. To this, they added that the events “could have been avoided if the doctors had been listened to” (Guérin Reference Guérin2011, 498). The timing of the strike, just prior to the collapse of the Trente Glorieuses, was fortuitous. The Ministry had just published the March 1972 order and circular, casting renewed attention on the May 1955 funds for social ills. Local authorities quickly complied with strikers’ demands, announcing “a happy solution to the conflict through the adoption of exceptional measures and financial means” (Guérin Reference Guérin2011, 498).

The more that policy-makers turned to this financial tool to placate workers, the more the workforce grew. Consider what occurred in Angers over the following decade. Between 1970 and 1977, the number of nurses, caregivers, and social workers (personnel soignant) grew from 744 to 992, an increase of more than 30 percent. During this time, the mental health service also added two chief psychiatrists and consequently two medical secretaries. The number of hospital interns almost doubled (from 17 to 31). Spending on nurses alone tripled, taking up an expanding proportion of the départements’ medical budget (Guérin Reference Guérin2011, 525–26).Footnote ³³ Moreover, this personnel boom continued even as the number of inpatients was plummeting, from 1,959 to 1,242 (Guérin Reference Guérin2011, 615, table 1).

The second feedback loop therefore demonstrates how intensification of worker demands, engendered by the events of May 1968, prompted public managers to expand the workforce and, by extension, support the expansion of psychiatric sectors. Their proliferation helped to further deinstitutionalization, as they allowed hospitals to more quickly discharge long-stay patients. The coincidence of this period with the Trente Glorieuses allowed for the “happy” disbursement of government funds at the local level. Moreover, this economic boom would soon come to an end. The third and final feedback loop shows how the empowered public mental health sector confronted economic crisis.

Public Mental Health Workers and Managers Resist Cutbacks at the Local Level

Despite pressures to reduce financial support for psychiatric hospitals and services, public psychiatry workers in the sectors continued to demand revenue increases from their managers. President Giscard d’Estaing’s reforms to health insurance (assurance maladie) had slowed, but not halted, hiring in psychiatric services (Ayme Reference Ayme1995, 281–82). Still profiting from the May 1955 funds for social ills, the sectors remained jointly financed by local health offices (commonly referred to as the Direction départementale des affaires sanitaires et sociales hereafter DDASS) and discretionary central government funds (simply referred to as the State, l’État). Moreover, the financial responsibilities of DDASS had lowered to just 17 percent of costs. Observers have remarked that this arrangement, by then referred to as double financing (double financement), was “particularly ‘heretical,’ but of unparalleled efficiency in developing a dynamic public health policy” (Bauduret Reference Bauduret2002).

The Managers’ Demay Report Proposes a “French” Approach to Psychiatric Deinstitutionalization, with Protections for Public Workers

In 1982, an important window of opportunity opened for public managers to further exert their influence. The defeat of Valéry Giscard d’Estaing by François Mitterrand, a Socialist, ended 23 years of governance by parties of the Right. With Mitterrand’s election, the Socialist Party sought to finally implement the “Common Program” (Programme commun), a set of Keynesian domestic policies jointly adopted by the Socialist and Communist parties in 1972. When the Socialists released their platform in advance of the election, they had promised to develop sectorization.Footnote ³⁵ What is more, shortly after the election, the new Health Minister, Communist Jack Ralite, personally attended the Syndicat’s conference in Sotteville-lès-Rouen (October 1981). “Far from suppressing jobs,” he declared, “psychiatry must create them.”Footnote ³⁶

Proposing that more sectors should be created to support an even smaller catchment area (50,000 people), he concluded with an invitation to the author of a new report:

The opportunity to directly influence government policy was welcomed with enthusiasm by the Syndicat and public mental health workers. “We could only rejoice at the Minister’s speech,” the labor leader Dr. Ayme reflected; “It even went beyond what we had ever dared to claim in terms of the size of the population served by sectors.” As for the choice of Dr. Demay, it “deprived us of a member of the union hall in exchange for a reliable and fraternal technical adviser” (Ayme Reference Ayme1995, 375). The next issue of Vie sociale et traitements (1981, number 137), the principal journal of sectoral workers, published Ralite’s speech in full as its special feature. Mental health workers thus applauded the new government and the auspicious opportunities it offered them (Ayme Reference Ayme1995; Jaeger Reference Jaeger1989, 22; Leguay Reference Leguay2002, 15).

Throughout Demay’s report, the preferences of public psychiatrists superseded those of private psychiatrists. Typically, the president of the Commission on Mental Illnesses would expect to author a government-mandated report on mental health such as this one. But the Commission presidency had recently rotated to a private psychiatrist, Professor Kammerer. By instead choosing Dr. Demay as the report’s author, Minister Ralite ensured that the report would take a public sector approach to mental health provision. For most of the 1970s, Demay had led the Commission’s subcommittee on sectorization.Footnote ³⁸ Long interested in formalizing the sectorization project into law, he organized a three-day colloquium in 1977 to develop the idea (Leguay Reference Leguay2002, 15). Moreover, the addition of his wife, Dr. Marie Demay, a pediatric psychiatrist in the public sector, as coauthor of the report contributed further to its public sector orientation (Demay and Demay Reference Demay and Demay1982; Faraggi and Dayot Reference Faraggi and Dayot2016; Leguay Reference Leguay2002, 15).

Contrasting “the French way” of deinstitutionalizing with the British, American, and Italian experiences (see Box 5.1), the Demays (and, by extension, the Syndicat) proposed anchoring their envisioned sectorization project in “public sectoral establishments” (établissements publics de secteur). These broadly defined community establishments would assume the responsibilities – and with them, the sustained, stable payment mechanisms – historically associated with mental hospitals. To justify this approach, the Demays looked to their country’s long tradition of “great public services, recognized for the importance of their role and the quality of their personnel” (Demay and Demay Reference Demay and Demay1982, 5). This emphasis on personnel reveals much about the agenda driving the report, another tool for brokerage.

For many years, sectoral workers had relied on the May 1955 social ills funds to obtain the high revenues necessary for their employment, but the instability of this mechanism prompted a more ambitious agenda: the “unification of personnel statuses” (unification du statut des personnels). The segregated financing of psychiatric hospitals (statutorily covered by Social Security) and non-hospital sectoral services (discretionarily covered by the May 1955 social ills funds) had produced two classes of mental health workers: those with positions inside the hospital whose employment could rely on stable Social Security revenues and those positions outside the hospital whose employment depended on the fluctuating social ills funds. (The timeline in Table 5.1 helps to illustrate this division.) While the Syndicat had begun to actively support the unification agenda in the late 1970s, it was through the Demay Report that the managers found an opportunity to communicate those demands to policy-makers most directly (Ayme Reference Ayme1995). By transferring all sectoral services to Social Security, the new establishments would lead to the “disappearance of the current inequalities produced by differences in the authority responsible for payment … in particular regarding the cases of certain nurses, social workers, psychologists, [and] medical staff” (Demay and Demay Reference Demay and Demay1982, 21). The report was released in July 1982, and in 1983 Vie Sociale et Traitements released a full special issue (number 146) celebrating the recommendation. This widespread optimism would, however, soon turn sour in the face of Mitterrand-era austerity measures.

Positive Feedback Develops Legal Protections for Mental Health Sectors, Despite the “Turn to Austerity”

Economic pressures to reduce mental health expenditures reached a tipping point in 1983. The Common Program had failed so spectacularly to meet the standards of the European Monetary System that Mitterrand scrapped the agenda altogether.Footnote ³⁹ In a landmark shift known as the “tournant de la rigueur” (turn to austerity), the president’s branch of the Socialist Party turned away from the Communist and more radical wings of their governing coalition (Levy Reference Levy1999; Vail Reference Vail2010). Moreover, the government’s tone toward mental health changed substantially. When outlining policy goals in the Ninth Economic Plan (1984–88), Mitterrand unveiled a massive reduction target for psychiatric beds that rivaled the aggressiveness of the Reagan and Thatcher administrations abroad: the suppression of 13,000 beds and the conversion of another 28,000 (Commissariat général du Plan 1982; see also Biarez Reference Biarez2004, 517; Coffin Reference Coffin, Gijswijt-Hofstra, Oosterhuis, Vijselaar and Freeman2005, 240; Jaeger Reference Jaeger1989, 22). Here was a classic case of crisis-induced deinstitutionalization.Footnote ⁴⁰

The Syndicat-supported Demay Report would play an important role in protecting mental health workers from Mitterrand’s turn to austerity, but at first the Ministry ignored the report. Mitterrand reconfigured his Cabinet, now appointing Edmond Hervé to the Health Ministry. The Commission did not meet for several months. “Rumors emanating from the cabinet suggested that the [new] minister was in favor of this ‘hibernation,’” Dr. Ayme (Reference Ayme1995, 344) remembers. Moreover, when the Commission eventually convened, the presiding civil servants made no mention of the Demay Report (Jaeger Reference Jaeger1989, 22).

Instead, the Ministry privileged the recommendations of another document. Commissioned under the austerity of the previous Barre government and hence published shortly before the Demay Report, the Gallois–Taïb Report (1981, 44–47) had proposed reducing psychiatric services by integrating them into the general hospital system. Although it too denounced the system of “double financement,” the Gallois–Taib report argued that the problem could be resolved by relying more on the private, not public, sector. The marginalization of the Demay Report, as Denis Leguay (Reference Leguay2002, 17) commented, was “like a sort of burial of the Sotteville speech [by Health Minister Jack Ralite]. Was it too ambitious, [too] costly in terms of human resources?”

Moreover, the laws of January 19, 1983, and January 3, 1984, applied three additional austerity measures to the hospital system by (1) extending the global budget to all CHU hospitals, hence (2) formally imposing a fixed hospital spending growth rate (taux directeur), and (3) terminating the system of “double financement” that allowed both the State and the départements to jointly finance services (Safon Reference Safon2017). The first two reforms, intended for the CHUs, did not trouble mental health workers as much as the third. Individual social services (a hospice, a rehabilitation center, a clinic) would now receive payments either from DDASS or from the State, but not both. This change gave each payer greater discretion over the services they would choose to fund, prompting the adage “whoever pays, decides” (qui finance, décide) and preventing services from using second payers as reinforcements (Reynaud et al. Reference Reynaud, Lopez and Coudert1994, 255–56). In the area of mental health, the State became responsible for all non-hospital sectoral services, as Table 5.1 shows (Ayme Reference Ayme1995, 247; Bauduret Reference Bauduret2002; Leguay Reference Leguay2002, 143). This decision depleted spending on sectoral services by almost a fifth (the 17 percent of costs that had been typically covered by DDASS).Footnote ⁴¹

There are different interpretations of what happened next. State policy-makers claimed that the Ministry of Finance never transferred the DDASS funds to the State and refused to finance any spending increases, in order to pressure the Ministry of Health to eventually charge the bill to the Social Security system (Bauduret Reference Bauduret2002). Alternatively, mental health professionals rebuked the State’s “forgetfulness” as yet another blanket austerity measure (Ayme Reference Ayme1995; Jaeger Reference Jaeger1989, 23–25). Regardless of the intent behind policy-makers’ forgetfulness, the end result was that the government had reduced financial support for community psychiatry.

It did not take long for mental health workers to respond. With nearly 85 percent of mental health spending going to personnel, the new budgetary reductions forced prefects of the départements to terminate contracts, reduce shifts, and forego replacements for outgoing personnel.Footnote ⁴² On June 28, 1985 the Syndicat, the Trade Union of Psychiatry, and the CGT Federation of the Île-de-France (Paris) region, organized a protest in front of the Ministry of Health in Paris (Ayme Reference Ayme1995, 418). At its meeting the next day, the Commission denounced the situation as “perfectly intolerable.” The “unilateral decisions” taken by the government had resulted in the “disruption of the entire health care system, challenging jobs and relationships, imposing drastic decisions for budgetary reasons alone, ignoring both needs and technical requirements” (quoted in Ayme Reference Ayme1995, 418).

Upon hearing the statement, the coalition of managers and workers organized an even larger protest on September 20, following it with significant media attention. Hundreds of psychiatrists, psychologists, psychometricians, nurses, and social workers protested in front of the ministries responsible for resolving the budgetary “error” (Ayme Reference Ayme1995, 418). In that month’s issue of Vie sociale et traitements, the CGT, the FO, and the Trade Union of Psychiatry published statements condemning the lack of funds.Footnote ⁴³

That same issue of the journal also explored ways in which the situation could be used to mental health workers’ advantage. They had been eyeing the development of global budgeting for several years.Footnote ⁴⁴ Although they were critical of the government’s use of the global budget as a tool for austerity, some wondered whether a guaranteed global budget would offer non-hospital sectoral services more stability than the billing per episode that had been in place, especially when “episodes” in community care included relatively inexpensive services such as a group workshop or a short outpatient clinic visit. In a piece entitled “What the Global Budget Could Be,” Jacques Ladsous, a special needs educator, reflected on the demerits of the fee-for-service system for mental health care and, in particular, its susceptibility to further retrenchment: “All it takes is to suddenly define ‘a day’ in a more precise way … and to demonstrate that a certain number of days were counted unduly. It would be enough, for example, to reduce the notion of ‘a day’ to the notion of ‘accommodation.’”Footnote ⁴⁵

In short, some mental health workers warmed to global budgeting as payment system that gave them more flexibility than the current fee-for-service system. Although the global budget could be reduced from year to year, the fee-for-service system could undergo more specific and restrictive regulatory changes that would make delivering comprehensive psychiatric services more difficult.

The Ministry seemed to have picked up on some workers’ openness toward global budgeting as an opportunity to resolve the “financial stalemate” (impasse financière, Bauduret Reference Bauduret2002). It returned to the Demay Report, using it now as a template for new legislation that would satisfy both mental health workers and, ironically, the government’s austerity program. Here the “adaptive expectations” mechanism discussed in Chapter 1 appears to have been at work. Although this mechanism is perhaps the most difficult to document in the two previous feedback loops described in this chapter (where only archival and other historical documents are available), I was able to assess its relevance to the third feedback loop by interviewing a former civil servant at the Ministry’s Bureau of Psychiatry and lead author of the reforms. The senior official told me that he had drawn on the Demay Report in part because he knew that the prefects feared, above all, the labor protests (“mouvements sociaux”) that often came with implementation. The Ministry had long been aware of this concern, having tracked the labor agitation on the ground for at least the last decade.Footnote ⁴⁶ The law that was subsequently proposed, and passed, on December 31, 1985, extended global budgeting to all CHS (the public psychiatric hospitals) and included sectorized services as part of that reform.Footnote ⁴⁷ The laws thus “legalized” the sectors by guaranteeing their statutory coverage by Social Security, and in doing so, upgraded the status of sectoral workers outside the hospital (see the last row of Table 5.1).

Through mass mobilization and the strategic use of the Demay Report, therefore, public workers and their organized managers gained a significant concession from a fiscally strained government. The protection and expansion of the public mental health sector was the product of workers’ pressure on their managers to expand revenues and protect their employment – pressures that had grown over time and reached their tipping point during this third feedback loop. An independently organized and unified group of public managers, the Syndicat, communicated these demands to government clearly and unequivocally.

Including sectoral services in the CHS global budget had important implications for deinstitutionalization. Hospitals had little incentive to increase their inpatient activity. Rather, the prospective global payment encouraged them to re-deploy care to the community setting early and often (Leguay Reference Leguay2002, 21). The result was the accelerated development of diverse, non-hospital sectoral services. By 1989, the country had developed more than 1,000 (Jaeger Reference Jaeger1989, 30). Today, France’s 1,232 sectors not only meet but in fact exceed the Syndicat’s original target (1,200, Chevreul et al. Reference Chevreul, Brigham, Durand-Zaleski and Hernández-Quevedo2015, 147). Their success stands in stark contrast to the intentions and operations of their counterparts in America, presented in Chapter 4.

Alternative Explanation 1: An Absent Social Movement?

Apart from the 1968 student and labor movement, which benefited the expansion of the public mental health workforce, other social movements are absent from the story of psychiatric deinstitutionalization in France. Public pressure to deinstitutionalize, therefore, seemed limited, in mirror opposition to the American case, where pro-deinstitutionalization sentiment gained strength.

Why is this? The strength of the public mental health workforce, once again, appears to be part of the explanation. If American public mental health workers were not sufficiently powerful to respond to the attacks of those critical of public psychiatry, French workers were just the opposite. A review of the historical evidence suggests that French mental health workers managed to both anticipate and suppress public criticism in ways that ultimately facilitated the expansion of their service.

“Anti-psychiatry” in fact held little sway in France (Henckes Reference Henckes2007, 22). Certainly, France is famous for producing academics who drew on psychiatry and psychoanalysis for their social critiques.Footnote ⁴⁸ But many, if not most, of these thinkers – Michel Foucault, Gilles Deleuze, Félix Guattari, Jacques Lacan, and even the postcolonial theorist Frantz Fanon – positioned themselves more as users, not necessarily critics, of psychoanalytic thought and practice. How society controlled madness, many believed, illuminated numerous questions about the social order. “We are careful not to demand the abolition of these [psychiatric] hospitals,” explained a nuanced letter cosigned by Deleuze, Lacan, and others, published in Le Monde.Footnote ⁴⁹ Only a few radical offshoots of those critics (e.g., the Foucauldian-inspired Asylum Information Group, or Groupe information asiles) seriously engaged the question of whether the entire psychiatric system should be overturned.Footnote ⁵⁰ In broader public discourse, that question never quite materialized.

Public psychiatrists, for their part, preempted it with a coherent response. In the mid 20th century, many psychiatrists were themselves deeply critical of the social control functions of the psychiatric institution. For example, in a series of writing produced in the 1970s, Henri Ey and his colleagues expressed their shock at being considered “jailers” in the country where Philippe Pinel famously freed the mentally ill from their chains (Coffin Reference Coffin, Gijswijt-Hofstra, Oosterhuis, Vijselaar and Freeman2005, 240). For reasons such as this one, public psychiatrists developed their “institutional psychotherapy” method (described in Chapter 3) to promote more social forms of treatment – but from within the walls of the public mental hospital.Footnote ⁵¹ Thinkers such as Guattari and Fanon trained precisely at the hospital where “institutional psychotherapy” first emerged (St. Alban), rendering them even more likely to support this method. It helped to lay the intellectual foundation for the sectorization policy, which some even framed as a form of anti-psychiatry itself (Martin Reference Martin2004).

To be sure, psychiatrists were not immune to criticism after institutional psychotherapy developed, including from some of their own coalition partners. At a conference of the Syndicat in 1974, a collective of nurses and other mental health professionals presented a 310-page report exposing psychiatrists’ demagoguery. (That these groups formed alliances in politics does not mean that they always got along in the workplace.) Soon thereafter, the public accused the Syndicat, with its historical ties to the French Communist Party, of sympathizing with Soviet psychiatry and its full range of horrors. At its 1978 conference in Deauville, the Syndicat developed a broad public relations strategy to respond to these critiques. The 300 participants assembled to recast the union as both a scientific and a labor organization and to formulate a coherent intellectual response to their critics that justified the protection of public psychiatric services (Ayme Reference Ayme1995, 326–27). The papers presented emphasized the therapeutic justification for public psychiatry, extending and rejuvenating the concept of sectorization to refute its harshest critics. Through a series of promotional events and press – both in France and overseas – they worked to distance themselves from the Soviet Union and authoritarian approaches to psychiatry as a whole.Footnote ⁵²

With the exception of the collective just described, however, mental health workers generally contributed to efforts to refute anti-psychiatric critiques. Union activists combined an intellectual reframing of anti-psychiatry with cunning mobilization strategies. Drawing on both archival sources and oral histories, Alfandari (Reference Alfandari2017, Reference Alfandari2018) examines how CGT militants defined themselves as both political leftists who opposed the authoritarian “asylum” and loyal employees of the publicly funded sectors. Meanwhile, Bouhallier (Reference Bouhallier2021) has discovered archival evidence that unions actively mobilized patients and their families to contest hospital closures in the postwar period. In other words, the unions representing mental health workers played a direct role in amplifying client demand for services and support for the psychiatric establishment. Together, public psychiatric workers and managers reinforced a mental health policy paradigm that made little room for anti-psychiatric critiques.Footnote ⁵³

Alternative Explanation 2: The Central Authority of l’État

Over the second half of the 20th century, France’s powerful and centralized État (State) appeared to become even more so. Gaullist public policy adopted a top-down, dirigiste approach to managing the economy, which a commanding bureaucracy implemented. This approach may have advantaged the French public mental health workforce, which unlike its American counterparts faced fewer institutional veto points that checked its influence. Personal accounts of how the 1960 administrative circular came to be illustrate this pattern. The bureaucrats’ influence was notable. Their Parisian office, Dr. Ayme’s memoir recalls, “was the control tower for all of psychiatry in France and its overseas territories” (Ayme Reference Ayme1995, 52). Once the Syndicat gained the ears of the bureaucrats, though, these policy-makers were “conquered by the idea of the sector” (Daumezon in Murard and Fourquet Reference Murard and Fourquet1975, 185).

Recall, though, that State bureaucrats were unsuccessful at implementing sectorization policy during the first feedback loop. Even if the Ministry did come to support the policy in the 1960s, the fact remains that few sectors developed at the height of dirigisme. This “long sleep” lasted until 1968. At that point, managers and workers allied to expand public employment opportunities in public psychiatry as a whole. Only afterwards did sectors proliferate.

State enthusiasm for sectorization then cooled during the second feedback loop, just as services expanded. While health care cost containment was becoming a priority in Paris, départements were turning to the “social ills” funds to increase mental health care expenditures. This conflict between national and subnational levels of government belies stereotypes of France’s unitary government structure. The reality is more complicated. Mental health workers and managers lobbied across a range of local institutions and their representatives, including elected officials on departmental councils (conseils généraux, or conseils départementaux as of 2015), mayors heading municipalities, as well as local labor dispute settlement and planning bodies (e.g., commissions paritaires départementales, comités techniques).

The incentives of policy-makers in these local institutions differed from those of their counterparts in Paris. Public psychiatric services were “a bit like the mine of the region, the big company around which the village economy revolved.”Footnote ⁵⁴ Local leaders were concerned about maintaining local employment and could exploit central funds to do so. Moreover, left partisans have historically been very responsive to local public sector trade unions, granting them much more power in some regions compared to others (Vincent Reference Vincent, Bach and Bordogna2016), and even compared to the national level. Indeed, unions in France have less direct influence on national policy than their counterparts in textbook corporatist countries such as Germany. But again, local incentives differ, in ways that in the 1970s benefited local mental health workers.Footnote ⁵⁵

The financial strain and austerity policies of the 1980s made the State even more committed to cost containment during the third feedback loop (Bauduret Reference Bauduret2002). It attempted, but did not fully succeed, to make drastic cuts to psychiatric services. Rather, the State agreed to a compromise proposed by the coalition itself. The following section will consider to what extent this compromise was part of the broader economic plans of that decade; however, it is unlikely that sectors would have gained national attention had they not already become staples of local economies in the previous decade. In some ways, sectors had developed against the prerogatives of the otherwise powerful État.

Alternative Explanation 3: The Role of Public Employment in the French Political Economy

French policy-makers have often expanded public employment for strategic political and economic reasons. After 1968, the new public sector positions would help to satisfy young protestors’ demands for employment. In the 1980s, the Mitterrand government restricted public employee wages to achieve the fiscal austerity and internal devaluation required by the European Monetary System, while also adhering to the Socialist government’s political commitment to Keynesian-style full employment. To compensate for the high unemployment of this period (exacerbated by the restructuring and industrial sector layoffs that followed the oil shocks), French policy-makers expanded public – albeit low-paid – employment (see Di Carlo Reference Di Carlo2023, also confirmed in personal communication). To what extent can these political strategies explain the expansion of public mental health employment? To what extent did the advocacy of the welfare workforce, especially in mental health care, shape those outcomes?

Not all segments of the public sector workforce benefited equally from these targeted expansions.Footnote ⁵⁶ Perhaps the most illustrative contrast comes from disability policy, a close cousin of mental health care but, in this case, also its competitor. Over the latter half of the 20th century, services for people with physical disabilities developed a private, not-for-profit, and targeted character, never gaining the full Social Security coverage that the public and universal mental health sectors did (Barnard Reference Barnard2019a, 766). Had French policy-makers sought to expand public employment irrespective of workers’ demands, one would expect similar policy outcomes in the disability sector as in mental health care. But that did not occur.

This divergence is partly attributable to the strength of public mental health professionals, who in effect feared losing their clients to another social sector. Note that the cards were stacked against them. In 1975, an association representing the families of people with mental illness managed to get a law passed that encouraged the transfer of residents of mental hospitals into the not-for-profit “médico-social” sector.Footnote ⁵⁷ But two articles of this law were particularly troubling to public psychiatric workers. Article 46 established separate services for the care of “dependent adults with chronic medical needs,” and Article 47 promised a decree detailing the conditions under which the State would cover “the expenses incurred in establishments receiving mentally ill persons whose condition no longer requires care in a psychiatric hospital but does require temporary medical supervision.”Footnote ⁵⁸

The public mental health workforce responded by actively opposing those provisions, and they succeeded. Scholarly accounts point unequivocally to how powerful public psychiatrists, in particular, shaped this outcome (Barnard Reference Barnard2019a, Reference Barnard2019b; Henckes Reference Henckes2007, Reference Henckes2011a, Reference Henckes2011b). The profession would play an important role in defining the disabled, as doctors have in other countries (Stone Reference Stone1984). But notice that French psychiatrists had specific economic interests at stake. Debates from the Syndicat’s 1978 Deauville conference – one already sensitive to employee demands – reveal the managers’ concerns about the potential for service competition (as opposed to the eligibility criteria of insurance benefits). One important paper proposed adding “intermediary structures,” a public sector alternative to those proposed in the 1975 disability law, to the sectors.Footnote ⁵⁹ In particular, “therapeutic apartments” would shift patients from the hospital setting to a less medicalized, more community-oriented one.Footnote ⁶⁰ These facilities were anchored firmly in the public sectorization system and offered more job opportunities for their sectorized employees than for themselves. (Such services are far less medicalized, and thus less dependent on physicians, than hospitals and outpatient clinics.) By the end of the 1978 conference, the Syndicat had passed several new resolutions. They denounced the disability law’s “serious risks of developing a network of institutions parallel to the public service” and renewed “its demands for ‘a financial tool’ that would be adapted to the situation” (Ayme Reference Ayme1995, 328). To date, those resolutions have been largely reflected in public policy: The comprehensive set of mental health sectors gained stable Social Security coverage in 1985, while disability services remain privately provided and less generously funded.

This 1985 law, it should be added, achieved goals different from those of French macroeconomics at that time. Although the Mitterrand government prioritized young people entering the labor market for the first time, the 1985 law that legalized mental health sectors primarily affected those already employed. In fact, it did more to strengthen existing public sector jobs (by converting département-run outpatient care into more stably financed services) than expand them. This outcome, too, was the direct result of the advocacy of the welfare workforce. The Mitterrand government may have sought to expand public employment overall, but in mental health care it did so according to the specific terms set forth by the public labor–management coalition in that sector.

Certainly, not all has been positive in French mental health care since 1985. Coordination with the disability sector, ironically, has become a challenge. Austerity measures have made it difficult for outpatient services to meet demand, especially for psychotherapy. They have also incentivized staff flight to the private sector, not unlike the “YAVIS” phenomenon described in the previous chapter did in the United States (Bauduret Reference Bauduret2022).Footnote ⁶¹ Although the overall financial structure and universality of the French mental health system has not been seriously challenged, it is notable that these strains began to appear as psychiatric management fragmented. At least four other unions of hospital and sector psychiatrists have emerged (Karavokyros Reference Karavokyros2010). Moreover, public managers trained in medicine, previously represented exclusively by the Syndicat, are less the norm now than before. The 2010 creation of regional health agencies (agences régionale de santé), as Tartour (Reference Tartour2021) has highlighted, deepened the fragmentation of the mental health care administration as well. These divisions may make coalition formation and continued advocacy for service expansion more difficult for mental health workers, even if their primary employment protections have long been secured.

In comparative perspective, though, the “French way” of deinstitutionalizing psychiatric services produced higher levels of public mental health care than in many other countries. One cannot explain this contemporary outcome without acknowledging the historical role of the welfare workforce. A coalition of workers and independently organized, unified managers advocated to develop, expand, and ultimately sustain mental health sectors, the diversified set of services that would complement institutional care. That public mental health care withstood austerity, though, is not unique to France. The next chapter shows how a similar pattern shaped the expansion of services in Norway and its absence facilitated their decline in Sweden, as they did in the United States. This shadow case comparison of two otherwise generous social democratic welfare states can assess whether and how the argument presented in this book generalizes to other countries.

Table 5.2Within-case process-tracing tests, France