Education, Treatment and Welfare Systems for Mentally Disabled People and Intellectually Disabled Children and Adults in France
Yokohama Research Institute for Disability, Education and Industry
I. Formation and Current Status of Subregional Psychiatric Treatment Teams1)
A reforming government notification promulgated in 1960 brought about tremendous changes to the psychiatric treatment system and was implemented between 1972 and 1974.
By 1983, 775 subregional psychiatric treatment teams had been established for adults,
with each subregion containing an average of 71,700 people.
In the case of infants and children, 286 teams had been established containing an average of 194,000 people.
There were 1700 free psychiatric clinics, which carried out 600,000 consultations and 855,000 home visits annually.
Regarding inpatient hospitals, there were:
84,000 beds in central psychiatric hospitals
18,600 beds in private hospitals contracted by prefectures
17,400 psychiatric beds in general hospitals
There are a variety of public and contracted private outpatient subregional facilities (free psychiatric clinics, day care centers, afternoon admission facilities, overnight admission hospitals, rest homes, primary reception centers, centers for responding to sudden deteriorations, apartments for treatment).A further government notification on minimal conditions for subregional psychiatric treatment teams was issued in 1990.
One team was established for 70,000 people for adults and every 200,000 people in cases of pediatric psychiatry. 50 beds were provided per sector (35–63 beds), with 10 beds (5–15 beds) for cases of pediatric psychiatry. Inpatient beds in psychiatric hospitals were gradually reduced and there was an increase in various types of outpatient facilities. As regards psychiatric treatment teams for infants and children, sites for reception and outpatient treatment called CMPs (centres médico-psychologiques—medico-psychological centers)2) were put in place. A treatment team was established for each population of around 200,000 people to provide examinations, outpatient treatment and inpatient treatment according to symptoms for patients up to the age of 16.
II. Representative Associations2)
90% of facilities and services for disabled children and adults are managed by representative associations. However, child protection groups (France's ASE and PJJ) are managed by public authorities, while groups for the elderly are managed both publicly and privately on a for-profit basis.
Associations in France play a major role, but their relationship to government authority can sometimes be unclear. Such associations include the National Consultative Council of Disabled People, which is a formal decision-making body that discusses cooperation with government authority. In addition, there is also a committee for agreements of representative associations of disabled people, which has two "unofficial" decision-making bodies that ensure lobbying activities during discussions between associations. A good account of the present state of associations has been provided by Camberlein.
III. The Orientation Law in Support of Disabled People (La loi d'orientation en faveur des personnes handicapées) of 1975 and the Law of February 20052)
The Orientation Law in Support of Disabled People (La loi d'orientation en faveur des personnes handicapées) of 1975 sets out two basic policies. The first is a career guidance law that assures the principle of national solidarity with disabled people to promote their independence and integration. The second is a specialized law that suitably positions social and decision-making bodies with responsibility for umbrella political activities involving surveys on disabilities, treatment, education, vocational guidance, employment, ensuring funding, social integration and access to sports and leisure.
However, there are no unambiguous definitions or classifications of disabled people, and clarification of disability is proceeding gradually. The promulgation of the ordinance “System of Terms for Functional Disabilities, Reduced Abilities, and Handicaps” of May 4, 1988 defined intellectual disabilities in a manner corresponding with the definitions of the WHO. However, mental disabilities and the like have not yet been adequately defined.
Furthermore, the 1975 Orientation Law in Support of Disabled People was revised with the enactment of the Law of February 11, 2005. The substantial principles of this law are as follows.
1. The rights of disabled people to national solidarity and to participate in political definitions of disability is reconfirmed
2. Guaranteed free life choices for disabled people
3. Aim to enable participation in social activities using various methods in cases involving the following:
- Entry to schools and higher education for children and students with disabilities
- Employment of the disabled
- General ease of access in living environments and public places, especially in cases involving buildings
4. Principle of compensation
In terms of welfare for the disabled, the term “handicap par maladie mentale” for the mentally disabled had been the cause of confusion with the term “handicap mental” for the intellectually disabled, and was changed to “handicap psychique,” and the Law of February 2005 explicitly provided the same rights as people with other disabilities3).
III. Treatment and Education of Intellectually Disabled Children and Adults4)
Until the Integrated Education Law, treatment and education was essentially carried out in medical and educational institutions (IMEs—Instituts médico-éducatifs). Historically, the first person to attempt institutional education (asiles-école) was Bourneville, one of the discoverers of tuberous sclerosis.
Nowadays, almost all treatment and educational facilities are managed by associations, but the costs are covered by social insurance (La Sécurité Sociale). However, staff involved in teaching are paid from national funding for education.
Prior to the enactment of the 1975 Orientation Law in Support of Disabled People (general principles set out in the Careers Guidance Law and enactment of and changes to detailed regulations mainly left to the government), intellectually disabled children were deemed unsuitable for school education based on a Binet-Simon test at the time of school entrance, and were ineligible for treatment in psychiatric hospitals unless they had particular psychiatric symptoms — thus, they spent most of their time at home. With the assistance of parents and volunteers, there was a gradual increase in institutions where these children could spend time. Additionally, psychiatrists would move around local regions, and the 1961 government notification restricted treatment in psychiatric hospitals for under-17s on the same basis as adults to clear cases of psychiatric symptoms or severe intellectual disabilities. If any education was possible, children were required to enter the instituts medico-pédagogiques (IMP—medical and education centers) established by the ordinance of 19561). At present, the following system for treatment and education is in place.
The system for treatment and education of intellectually disabled children is comprised of the following elements:
① Centers for diagnosing and treating young disabled children (CAMSP—Centre d’action médico-sociale précoce)
② 3–20 years old Treatment, education and training facilities Treatment and education are received at IMEs Residential facilities, weekday-only residential facilities and day centers are available, depending on individual circumstances
The names of IMEs change depending on age. In the 3–14 years age group, they are known as medical and education centers (IMPs), and in higher age groups, they are known as treatment and training facilities (Instituts médico-professionnels)
Members of staff at these facilities include physicians, paramedical staff, psychological staff, re-education teachers, special education teachers and subject teachers (provisional translation) called "enseignants".
According to the 2009 edition of the Guide du secteur social et médico-social (by Marcel Jaeger)4), there are 1213 centers nationwide in which 77,000 children are receiving treatment and education. Users of treatment and educational facilities make up almost 65% of this total. Furthermore, facilities for behavioral disorders (currently referred to as instituts thérapeutiques, éducatifs et pédagogiques (ITEPs—institutes for treatment, education and pedagogy). These are educational facilities for children with behavioral issues who, even if of normal intellectual ability, require the use of treatment and educational techniques for delayed academic progress. As of 2005, there were 342 such centers capable of handling 15,600 children) and CMPPs (centres médico-psycho-pédagogiques—child guidance clinics) are available for infants and children with psychomotor problems (dominant side problems, movement coordination, instability, depressomotor) or behavioral disorders (aggression, autism).
Medical tests are performed, pathological symptoms are diagnosed, and educational and treatment methods are used. Established alongside consultation centers for psychiatric teams for infants and children, there are 599 CMPPs handling 98,000 disabled children4).
There is also a service called SESSAD (Service d'éducation spéciale et de soins à domicile—Special education and home care service6). This is close to a CAMSP in that it is for early education up to the age of six years, but this age is not a cutoff. It is also provided by kindergartens, normal schools and service headquarters. In general, it provides multi-disciplinary specialists for children with more severe disabilities than in the case of CMPPs. Similarly, according to the 2009 edition of the guide mentioned above, there are 911 services handling 23,000 children.
Facilities for motor disorders, facilities for multiple disorders, facilities for hearing disorders, facilities for visual disorders and facilities for blind and deaf children also exist, but these will not be touched upon here.
In addition, following international developments in the field of integrated education and the establishment of the Orientation Law in Support of Disabled People in 1975, integrated education for disabled children started on the basis of the social solidarity aspect and national education aspects of the notifications issued in 1982 and 1983. In the case of children with intellectual disabilities, however, parents were generally not very keen on this. Nowadays, though, at least 155,000 students with disabilities of every kind (the number with intellectual disabilities is not known) are in integrated education.
IV. Recognition of Autism as a Disability1)
In France, autism is considered to be a childhood psychosis, and IMEs began a policy of accepting autistic children for education as disabled children in 1989. The compulsory acceptance of autistic children had to wait until the 1995 notification. It is important to note that this French policy has resulted in a large number of autistic children and adults in facilities in Belgium.
IV. Facilities for the Intellectually Disabled
Once they have reached adulthood, the following places are available for intellectually disabled people on a residential or visiting basis1).
① MASs (Maisons d’accueil spécialisées—Special reception centers for people with multiple disabilities) 3614 people
②CATs (Centre d’aide par le travail—Employment rehabilitation centers) 58,000 people
③ AP (Atelier protégé—Protected workshops) 6300 people
④ Meeting places called foyers de vie 4747 people
⑤ Lodging facilities called foyers d’hébergement 19,695 people
(Numbers of people are according to Leberman, 1984).
MASs are divided into residential facilities for the intellectually disabled, the severely physically disabled and for those with multiple disorders5). They are aimed at disabled people without obvious psychiatric symptoms. Influenced by trends in the movement for deinstitutionalization from psychiatric hospitals, these facilities have been created as intermediate psychiatric facilities for the intellectually disabled. According to the 2009 edition of the guide, there are 470 MASs, with 19,600 residents. MASs are entirely managed by the government. MAS staff members are mainly support workers, but there are also medical staff, paramedical staff and teaching staff. These MASs have developed as an alternative to psychiatric hospitals. When particular medical care is required, patients enter an FAM (foyer d’accueil médicalisé—a specialized medical center for people with multiple or severe disabilities). These facilities are under the dual jurisdiction of the national government and prefectural assemblies.
Treatment and education is also carried out in the MASs5). Education is aimed at developing ability to know and understand cognitive function and the surrounding environment, and increasing ability in a social dimension. Chavaroche observed that the distinction between treatment and education is an erroneous way of undertaking responsibility, and that a mutual, complementary relationship is essential.
1) Romain Liberman: Handicap et maladie mentale, puf, que sais-je? 2009
2) Philippe Camberlein: Politiques et dispositifs du handicap en France, DUNOD, Paris, 2008.
3) René Baptiste: Reconnaître le handicap psychique, Chronique Social, Lyon, 2005.
4) Marcel Jaeger: Guide du secteur social et médico-social, DUNOD, Paris, 2009.
5) Philippe Chavaroche: Travailler en MAS Trames
Reference was also made to the following for matters such as details of occupational duties and methods for qualification.
6) Johan Priou, Séverine Demoustier: Institutions et organisation de l’action sociale et médico-sociale, DUNOD, Paris, 2009.