La psychothérapie institutionnelle est un modèle d’élaboration du soin psychiatrique issu, au sortir de la Seconde Guerre mondiale, de la reconnaissance de l’effet pathogène de l’asile et de la subjectivité et de la singularité de la souffrance psychique. Elle a évolué à travers la psychiatrie de secteur. Elle préconise une utilisation de l’institution dans son aspect instituant, c’est-à-dire favorisant une dynamique des échanges ; l’institutionnalisation des différents lieux d’accueil du patient lui permet de se situer ou resituer dans sa dimension historique et symbolique. Elle privilégie l’analyse institutionnelle et la transversalité. Les fondements théoriques et la pratique de ce mouvement sont interrogés à la lumière des concepts organisateurs de l’éthique médicale. Il apparaît que sa démarche est conforme à l’exigence éthique par son intérêt majeur pour le sujet aspirant à introduire du sens dans sa vie. En cela, il se singularise par rapport à des conceptions récentes de la thérapeutique psychiatrique, liées à l’essor des neurosciences, la promotion de l’individu citoyen et de la pensée juridique, aux impératifs budgétaires. Ce contexte favorise, sous le primat d’une approche médico-technique et médico-économique, l’émergence de modes d’objectivation du patient et de compartimentation du traitement. Il est proposé que la psychiatrie opère, dans la continuité du mouvement de psychothérapie institutionnelle, un recentrement éthique par une recherche multidisciplinaire sur les principes, les méthodes et la politique du soin.

Historical aspects – The idea behind this work is to have an ethical examination of the institutional psychotherapy movement which has long influenced French public psychiatry and which has progressively, since the 80s, been subject to growing doubts. In the first part, institutional psychotherapy is presented. It is a model for theoretical development and practice in psychiatric care. It came into being just following the end of the Second World War at the same time as modern medical ethics. Its principles come on the one hand, from recognition of asylums" pathogenic effects – which led to the crushing of the patient’s being – and on the other, through recognition of the uniqueness of each person and the subjectivity of mental suffering. These elements gave rise to creativity within the world of medicine and, in the sector, generated the science of psychiatry which advocated for continuity in care (both inpatient and outpatient) and preventive work directed at the population. This movement called for the use of the institution in its dynamic aspect which promotes exchanges and allows patients to situate or resituate themselves in historic and symbolic dimensions. It privileges a high level of transversality, maximum communication, favouring speaking out loud and responsibility. It requires a permanent analysis of the institutional counter transference (emotional reactions of the caregivers involved, their interrelations and the social and material organization of the institution) which determines the therapeutic action itself. Theorical basis – In a second part, its theoretical foundations and its practice shall be investigated in light of the guiding concepts of medical ethics (justice, autonomy, beneficence, non-malfeasance). Institutional psychotherapy responds to the need for justice by considering the patient as a whole and by conceiving each patient as being like oneself despite the differences (associated with the mode of hospitalization, the social or diagnostic category). The principle of autonomy lies always at care’s horizon, made concrete in practice by notions of habitability, orientation to place and time, references, by activities and by meetings. The principle of beneficence was the basis for round-the-clock intakes, the use of an established theoretical model and clinical practice centred on the patient’s words. Institutional analysis attempts not to repeat the alienation felt by the patient, alienation being associated with the treatment environment, and draws from the principle of non-malfeasance. It therefore appears that the approach of institutional psychotherapy conforms with ethical requirements, given its major interest in the subject who aspires to find meaning in life. Current situation – The third part discusses current orientations in care related to the explosion in neuroscience and technology, the promotion of the citizen as an individual, and legal doctrine, budgetary constraints, and new demands made on psychiatry from the social and political domains. The widespread trend towards simplification, swollen with hypotheses from neuro­scientific research, is progressively reducing mental illness to target symptoms. The recovery of the notion of citizenship through technological capture and ideological strains in contemporary culture have also affected a suspension of the subject as a thinking and desiring being, and exempted caregivers from considering transferral phenomena, indicated with the appearance of new signifiers : user, stress, plague, network. The new medical-technical jargon of scales, tables, and management participates in the same process of patient objectification and care compartmentalization. In this context, under the cover of science and generally good actions, psychiatry has become biologisized, whilst being diluted from its social aspect, even as it becomes more repressive for patients. Conclusion – This observation leads to the conclusion, in the fourth part, that there is a need for psychiatry, which within its own discipline has a hard time finding sufficient resources, to

refocus itself ethically. This enlightenment could come within a multi-disciplinary ethical space, uniting practitioners and psychiatric caregivers, psychoanalysts, philosophers, sociologists, neurobiologists etc. The research should concern the legitimacy of the principles that underlie psychiatric action in its care and preventive aspects.