Les rencontres entre médiateurs de santé pairs et usagers de la psychiatrie en France : caractéristiques générales et effets du dispositif sur les représentations des usagers. Partie 1

Objectif : Cet article traite des rencontres entre des usagers de la psychiatrie et de nouveaux professionnels, les médiateurs de santé pairs (MSP), formés dans le cadre d’un programme expérimental français dirigé par le CCOMS (Centre collaborateur de l’OMS). Les données empiriques que nous présentons ici sont issues d’une enquête sociologique qualitative qui a participé à l’évaluation de ce programme, menée entre 2012 et 2014. Le programme MSP consiste à embaucher dans des services de psychiatrie publique, au terme d’une formation de huit semaines équivalant à un diplôme universitaire et d’une année de stage, d’(ex-)usagers de la psychiatrie, des personnes « ayant eu ou ayant encore des troubles psychiques, rétablis ou en voie de rétablissement ». Au-delà de la création d’une nouvelle profession dans le champ de la santé mentale, le programme s’est donné pour objectif la transformation des pratiques et des représentations des équipes de psychiatrie publique.Méthode : Soutenu par trois Agences Régionales de Santé (ARS), il a débuté avec 29 candidats à des postes de MSP et visait après la phase expérimentale à être étendu à d’autres régions, voire généralisé. À l’heure actuelle, 15 MSP sont en activité, sur contrat à durée déterminée renouvelable de la catégorie C de la fonction publique. Nous nous intéressons plus spécifiquement ici, dans une démarche ethnographique, aux rencontres entre patients et MSP : à leur contenu, leur forme, leur style, aux caractéristiques de ces interactions ainsi qu’à certains de leurs effets. Le matériel d’enquête exploité est composé de 74 entretiens semi-directifs avec les usagers et d’observations conduites dans les services, ayant permis d’analyser des échanges à la fois formels et informels.Résultats : Nous avons organisé l’analyse autour de quatre grands thèmes. Les deux premiers, qui font l’objet d’un premier article, concernent les caractéristiques générales de la rencontre et les effets du dispositif sur les représentations des usagers quant à la maladie et au système de soins. Les déterminants communs des rencontres que nous avons pu dégager sont les suivants : leur caractère volontaire ; une normativité moindre sur les comportements ; une offre de temps et de disponibilité ; un rapport distant à la médicamentation ; un déclivage vie privée/vie professionnelle ; une gestion spécifique de la distance et de la familiarité. Concernant les représentations de la maladie et du soin, nous montrons que les MSP contribuent à diffuser activement une idéologie du rétablissement fondée sur une conception positiviste de la personnalité. Ils s’autorisent également une certaine critique des autres professionnels et du système de soins et cherchent à s’en distinguer en privilégiant une philosophie de la patience et du « petit pas ».Objective: This series of two parent papers describes, as part of an experimental program in France, the meetings that took place between consumers of psychiatric services and peer mentors. We report on the shape, style and characteristics of these interactions. Some of their effects are also reported. The peer mentors are hospital employees who are hired through renewable contracts or, for some, on permanent contracts. The program was led by the World Health Organization Collaborating Centre for Mental Health for France, with the intention, beyond the creation of a “new profession,” of transforming current practices and representations of public psychiatry teams towards recovery. The first paper discusses the general characteristics of the consumer/peer mentor meetings and the effects of this mechanism on the representations of the consumers about mental illness and more broadly about the health care system. The second paper reports on the therapeutic effects of these meetings. Some limitations and pitfalls are highlighted.Methods: The program under study involved the hiring of (ex-) consumers of psychiatric services (n=29). These peer mentors are individuals “who have had, or still have psychiatric disorders, and have experienced a process of recovery.” They were deployed in public psychiatric services after having been trainees for a year and having pursued a training of eight weeks, in parallel, that led to a peer mentor university degree. Our sample is mainly composed of patients who met at least once with a peer mentor, and who were recruited during the field survey in the sites (in-hospital, outpatient or in urban settings). We approached and spoke to patients who were likely to agree to be interviewed to share their experience and thoughts. They had to sign consent forms and thus they were told that we were working on this experimental program on peer mentors with a qualitative and inductive approach. The empirical data that is reported here comes from a qualitative sociological investigation that accompanied the evaluation of the implementation of the program between 2012 and 2014. We have conducted 74 interviews with consumers. We have a significant number of observations of the meetings between peer mentors and consumers, some of which were transcribed verbatim. We were also informed by informal discussions with consumers in every service, and through direct interviews with peer mentors, as well as through in situ observations.Results: We used standardized prompt questions such as: “Did you meet X,” or “Do you know X?” We had to introduce the terms “peer” or “former patient.” In effect, in interviews with study participants it appeared that this “X” was sometimes perceived as more of a nurse, and that they were not aware that this person was a “peer mentor” or a former patient. The insistent style of some questions and the context of what could appear to be a formal assessment of a person’s work might explain why study participants seemed inclined to give positive comments. A bias was also possible when study participants were recruited and “prepared” by the treatment team for the interview. Despite these limitations, we can highlight the quality of the data.Conclusion: By the end of the experiment, 15 peer mentors were able to find and make their place in various services, despite important differences between situations with regards to their position in the institution, their degree of autonomy and responsibility, their working arrangements with other professionals, and their actual work. However, we were able to identify common determinants: the voluntary nature of the meetings; less normativity on behavior; the supply of time and availability; a distant relation to medical drugs; a blurring of boundaries between private and professional life; specific management of distance and familiarity. Concerning representations of illness and care, we found that the peer mentors actively contribute to disseminate a vision of recovery based on a positivist conception of personality. They also allow some criticism of other professionals and of the healthcare system. Consumers, in turn, evoke interactions based on the ease of contact, proximity and availability of peer mentors. This proximity can be linked to a form of camaraderie in the institutional context of care but can also lead consumers to see, in the peer mentor, a figure of “hope.