CAIRN-INT.INFO : International Edition

1 The title of this article—“People, not walls”—is a reference and a tribute to Lucien Bonnafé, who described himself as an “anti-alienist” and whose humanist, anti-asylum approach had a profound impact on French psychiatry. [1] This is consistent with the current mental health philosophy of the World Health Organization (WHO), which proposes a shift from institutional to individual health care services. Here the term “service” should be understood as the care provided, but also social support. The general principle underlying the work of WHO is to “think globally, act locally.” In this article, we will consider the main founding WHO texts that determine the orientations of its mental health policy (the Alma-Ata conference, [2] the Ottawa Charter, [3] and its action plans), which is based on three concepts: empowerment, recovery, and citizenship. The conceptual framework for the implementation of these three concepts is community mental health. Finally, we will illustrate these policy orientations using the specific example of integrated mental health services in the eastern suburbs of Lille. In French, the use of the term “communauté” in this context draws on the work of Jacques Hochmann and the Villeurbanne experiment. [4]

WHO and mental health

1978 Declaration of Alma-Ata

2 In 1978, WHO defined health as “a state of complete physical, mental and social wellbeing, and not merely the absence of disease or infirmity,” a statement that can be seen as a difficult-to-realize utopian revolution. WHO goes even further by describing health as “a fundamental human right.” This is true in France, but even more so for poor countries or countries at war or in conflict, where it becomes clear that health is a fundamental right for the people. This definition involves “the action of many [...] sectors” beyond the health sector. This is a description of the concept of health, not disease. And WHO adds: “The existing gross inequality in the health status of the people [...] is politically, socially and economically unacceptable [...].” Far from a neoliberal view of health, this definition does not ignore the social causes and determinants of health and disease, or social inequality: “The promotion and protection of the health of the people is essential to sustained economic and social development and contributes to a better quality of life and to world peace.” The guiding principle of the Alma-Ata conference was that “The people have the right and duty to participate individually and collectively in the planning and implementation of their health care.” If we speak in merely “individual” terms, we overlook the “collective” included in this declaration. There can be no health without both individual and collective responsibility for health. The conference also emphasized the importance of primary health care and the essential role of primary care physicians (PCP) in improving population health around the world. The figures in this article make it very clear that access to health care, which is essential for physical or psychiatric illness, is first and foremost a matter of primary health care. This is the first level of non-stigmatizing contact for individuals.

The Ottawa Charter

3 The 1978 Alma-Ata Declaration was followed by the Ottawa Charter for Health Promotion of November 21, 1986, which called for individuals to be given more control over their own health, and the means to improve it. The Ottawa Charter considers health as “a resource for everyday life, not the objective of living.” It is not a matter of physicians and health systems taking power in society, but of seeing health as a resource that belongs to everyone. Health is a positive concept with an emphasis on social and personal resources, and physical and mental abilities. Resource conditions are a prerequisite for health. In both psychosocial rehabilitation and mental health, social inclusion is known to be a major contributor to health: this requires housing, access to education, an adequate diet, a stable ecosystem, a reliable, sustainable supply of resources, and the right to social justice and equitable treatment. WHO has 195 member countries with very different political and social situations. In many countries, these conditions do not exist, or exist only in part.

The translation of the Alma-Ata Declaration and the Ottawa Charter into mental health

4 WHO declared 1960 World Mental Health Year, but this campaign went relatively unnoticed. During this period, the aim was essentially the creation of hospital-type facilities around the world, with WHO advocating a ratio of three hospital beds per one thousand people, much higher than modern recommendations. In 2001, as part of the Second Year of Global Mental Health, it called for the closure of large asylum facilities, the fight against stigma, and the defense of patients’ rights. Today, the organization is more focused on comprehensive mental health action plans than on determining the right size of hospital facilities. Its latest action plan is the 2013–20 plan, which was adopted by all 195 member states in May 2013. [5] In principle, all states that voted to approve this plan, including France, are required to apply it.

5 It consists of four objectives and recommendations:

  1. “To strengthen effective leadership and governance for mental health.”
  2. “To provide comprehensive, integrated and responsive mental health and social care services in community-based settings.”
  3. “To implement strategies for promotion and prevention in mental health.”
  4. “To strengthen information systems, evidence and research for mental health.”

6 It is important to note that the global disease burden of mental disorders is not adequately understood. The data are still patchy, with figures on morbidity and mortality costs not always available, and many countries do not have access to this information.

The European Mental Health Action Plan [6]

7 This is the local version for the fifty-three countries in Europe of the global plan that was adopted by WHO in 2013. Its objectives are as follows:

  • “Everyone has an equal opportunity to realize mental well-being throughout their lifespan, particularly those who are most vulnerable or at risk.”
  • “People with mental health problems are citizens whose human rights are fully valued, respected and promoted.” Rights are a key issue in mental health (on this, see the Robiliard report, which underlines the need to respect the effective rights of individuals who are hospitalized involuntarily, and which bravely raises the controversial issue of restraint and seclusion in psychiatric services in France). [7]
  • “Mental health services are accessible, competent and affordable, available in the community according to need.”
  • “People are entitled to respectful, safe and effective treatment.” And information on treatment must be transparent and complete.
  • “Health systems provide good physical and mental health care for all.” This refers to the gap in life expectancy between people with severe mental disorders and those without: the life expectancy of a man with a severe mental disorder is twenty years lower than the average, while the equivalent gap for women is fifteen years. This is not solely due to the risk of suicide, but also because of the physical consequences of lifestyle, addictive comorbidity, lack of access to physical health care, and medication side effects.
  • “Mental health systems work in well-coordinated partnership with other sectors.” This is intersectorality as understood by WHO: not in terms of working across different psychiatric services, but rather across social sectors such as health, justice, housing, work, education, and policing.
  • “Mental health governance and delivery are driven by good information and knowledge.” This is an important objective since data are sometimes patchy, the quality of data collection is poor, and inter-country comparisons are unreliable and therefore of limited use.


8 The concept of empowerment is not specific to the field of health care, but emerged during the struggles for the rights of oppressed women and African Americans. Empowerment means giving communities the opportunity to organize themselves. Above all, it gives minorities a means to fight in order to obtain respect and dignity. Information sharing, participation, mutual support, self-determination, and self-management contribute individually and collectively to empowerment.

9 In the field of health care, the battle fought by people living with AIDS in the 1980s for their rights to be respected profoundly changed the health sphere around the world. Along with the United States, France was one of the countries with the most organized movement to combat the epidemic, and this movement was strongly influenced by service user organizations around the world.

10 Little by little, these activists forced doctors to share medical knowledge, and to recognize the value of the experiential knowledge gained from living with the disease. This same experiential knowledge is found in patient education programs, in the experience of health peer mediators, and anywhere service users are involved in the organization of care, [8] in defending patients’ rights, or in relation to the dysfunction of the care system. Recognition that injured patients could act collectively via class actions was a new advance linked to this notion of empowerment.

11 Other advances in this area include the fight against social exclusion, which is both a contributing factor to poor health and a direct consequence of disease, and finally self-education and improving access to care.

12 Empowerment is at the heart of the vision of health promotion advocated by WHO. In the context of mental health, it refers to “the level of choice, influence and control that users of mental health services can exercise over events in their lives. The key to empowerment is the removal of formal or informal barriers and the transformation of power relations between individuals, communities, services and governments.”

13 In January 2014, the Lille Collaborating Center, WHO Europe, and the European Commission held a European meeting on empowering mental health service users and caregivers. This meeting produced twenty-one recommendations, divided into three sections, which were published online on the WHOCC website. [9]

14 The first section concerns the protection of fundamental rights, and focuses in particular, for the fifty-three countries of the WHO European Region, on the practices of seclusion and restraint. The evaluation of involuntary treatment practices is one of the constant demands from service users, through initiatives such as advocacy, which involves “promoting legal and judicial support for service users and caregivers and ensuring access to care.”

15 The second section deals with the organization and evaluation of care and connects with the WHO “QualityRights tool kit,” which proposes a series of actions to improve care, including inspections by service user organizations, in relation to the limitation of freedom. This tool kit can be used to study care quality from within services themselves. It also helps to ensure that service users and caregivers are integrated into all hospital care services. For psychiatry in France, this would involve ensuring the representation of service users and caregivers on division boards, departmental boards, facility non-medical committees, facility medical committees, and boards of directors. It also means developing networks and mutual support groups (groupes d’entraide mutuelle, GEM), in order to increase the number of people with the capacity to represent service users and caregivers.

16 The third section of the recommendations concerns the provision of information and communication about disorders and diseases. In France, this is starting to happen. It is essential to provide information about current service provision and the need for care that is accessible to and appropriate for mental health service users, and developed in conjunction with them. This is one of the missions of the Paris-based organization Psycom, which should be available throughout France. [10]

17 The creation of media watch groups to monitor the handling of information is also important. The “See Me” program in Scotland and its “Stigma Stop Watch” is an excellent example: it has a network of six hundred users and caregivers who can flag up information that they find to be stigmatizing or discriminating to journalists via email or social media. [11] All of these examples are available from the recommendations on the WHOCC website.


18 According to William Anthony, recovery is the culmination of change for the individual, and the achievement of a new equilibrium. He defines it as “a deeply personal, unique process of changing one’s attitudes, values, feelings, goals, skills and/or roles. It is a way of living a satisfying, hopeful, and contributing life even with limitations caused by the illness. Recovery involves the development of new meaning and purpose in one’s life as one grows beyond the catastrophic effects of mental illness.”[12] Above all, recovery is about finding new meaning in life. We can see the concept of recovery emerging in French legislation, in particular in the 2005 Disability Act. [13]

19 The term recovery emerged in the 1970s, and was used primarily by people with an alcohol use disorder who emphasized their capacity to manage their own lives and their treatment rather than their impairments. In a sense, they organized themselves to provide one another with care and support. In the United States and Canada, most mental health services are “recovery-oriented,” with their service charters stating they focus on the ability of individuals to recover. The Mental Health Commission of Canada has previously circulated an online petition in support of its Mental Health Strategy that emphasizes recovery and has been signed by all of the country’s key players in the field of mental health (psychiatrists, service users, and politicians). [14]

20 Cohort epidemiological studies show a high proportion of remission, including among people with severe mental disorders (including “schizophrenia,” a term strongly associated with non-recovery and stigmatization). [15] Epidemiological studies of what happens to people with schizophrenia, for example, show that 50 to 70 percent recover and go on to live a satisfactory or even normal life.

21 Promoting abilities, skills, and participation in collective life means moving from a biomedical model to a holistic “biopsychosocial” model. This has been a major paradigm shift for services. The care and services that were the business of professionals and institutions until the 2000s have now refocused on the power of patients to manage their disorders with support from professionals.

22 In the old asylum system, individuals had to adapt to the medical service, with iatrogenic incapacities eventually resulting from long-term hospitalization.

23 Recovery-focused care and services affirm the power of individuals, respecting their choices, hopes, and desires. Health care professionals must adapt to this new world, where capacities are increased in the search for a new meaning in life. [16]


24 Citizenship consists of being recognized as a member of a community or state, and having an active role in a shared project. This involves the recognition of the civil and political rights and civic duties of all citizens, in a democracy and a state governed by the rule of law. If citizenship is restricted by mental disorder, this creates second-class citizens: people who are not really citizens and therefore not part of our world. Citizenship is the guiding principle of recovery and empowerment.

25 The key component of recovery is not only keeping people in the community, but making them part of the community, in which they live like everyone else. This means considering everyone as a citizen, as a person rather than as a patient. And being part of the community requires the development of reciprocal relationships between equal citizens.

26 A team from Yale in the United States has developed tests to measure the citizenship of people with a mental disorder. [17] Recovery, empowerment, and citizenship are closely related concepts because they make it possible to invert relationships of dominance between the state and civil society, especially for the most disadvantaged social groups. [18] The conceptual framework for the development of these three concepts is community mental health.

Community mental health

27 “Community health is when members of a collective, whether geographic or social, jointly reflect on their health problems, express priority needs, and actively participate in the development and implementation of the actions that best address such priorities.” [19]

28 The Institut Renaudot, which specializes in community health, states that there must be a collective basis, a collective identification of problems and participation open to all the actors concerned, whether they are administrative or political, or service users. This means involving the population itself in identifying the problem, in order to draw on its capacities, ensuring it participates in the whole process, breaking down professional barriers, transdisciplinarity, multidisciplinarity, breaking down institutional barriers (intersectorality), partnerships, and sharing knowledge and power. This describes the ideal of community psychiatry at its inception.

Practical application of the WHO principles in France: An experiment in citizen psychiatry in the eastern suburbs of Lille

29 The development of citizen psychiatry represents a genuine form of advocacy for the empowerment and recovery of people with mental health problems. [20] Its legislative application in France came via the emergence of the concept of health democracy, through the Act of March 4, 2002, which gave patients, including people with mental disorders, direct access to their health data, disease information, affirmation of their rights, and patient education. [21] The Act of March 4, 2002 can be said to have transformed the relationship of citizens to the medical system. In 2002, its application in the field of mental health was made possible thanks to the Fédération Nationale des Associations d’usagers en PSYchiatrie (FNAPSY, National Federation of Psychiatric Service User Organizations), the Union nationale de familles et amis de personnes malades et/ou handicapées psychiques (UNAFAM, National Union of Friends and Family of People with a Mental Health Disorder and/or Disability), and the government report “La démocratie sanitaire dans le champ de la santé mentale. La place des usagers et le travail en partenariat dans la cité.” [22] The Act of February 11, 2005, on equal rights and opportunities, participation, and citizenship for individuals with disabilities, built on the 2002 Act by defining mental disability and its associated rights, and enabling the creation of mutual support groups (GEM) that could in theory be managed by service users themselves.

The Mental Health in the General Population (MHGP) survey[23]

30 This survey, conducted in eighty-six sites, including sixty-five in France, highlighted the issues of self-care and informal care. Here we will focus on the findings from the representative sample of the adult population of the East Lille psychiatric service (85,300 inhabitants, including 65,100 over 18 years old).

31 The number of people likely to have at least one disorder (anxiety, depression, addiction, or psychosis) as assessed by the MINI diagnostic instrument was 23,176 (30 percent), and for 11,000 people these disorders had a negative impact on daily life (such as on work, family, and social relationships). It is entirely possible to have a mental disorder identified by a diagnostic instrument without experiencing problems in daily life. These are not diagnoses as such—which would require a patient-doctor consultation—but rather they represent the likelihood of having a mental disorder based on a standardized tool. However, if 11,000 of these 23,176 people report an impact on daily life, this is not just a minority problem in the community. Of the 23,176 individuals identified as having a disorder by the MINI questionnaire, only 5,707 felt as if they were ill. They may identify and analyze their unease and mental suffering in terms other than those of disease, whereas psychiatrists label their problems as mental disorders.

32 Of these 23,176 positive responses, 14,963 individuals had sought help from friends and family, who were seen as the first port of call. In addition, 15,451 people had seen a PCP. This highlights the important role played by primary health care in access to care, screening, and treating people with mental disorders.

33 This is consistent with the study by Antoine Lazarus exploring why people access primary care, which found that PCP diagnose one in ten people who go to see them as soon as they walk through the door. [24] Another one in ten is diagnosed on the basis of further examinations and their health problem is resolved, and for eight out of ten, the question is finding out what they are doing in the PCP’s office, when they have no obvious physical disorders in the first place. Many of these eight in ten people are there to express physical and mental suffering and to do so indirectly to their PCP.

34 The survey also found that the number of individuals at medium- or high-risk of suicide was 3,711 in this population. But the risk is not suicide, this figure highlights the non-triviality of suicide in the population.

35 In comparison to these figures for the general population, in 2013, the East Lille psychiatric service saw just 3,007 people. Thus, of the people identified in the general population as having a mental disorder, only 15 percent were seen by the psychiatric service, and of this proportion, only 7 percent (214) were hospitalized.

36 Only half of those with depression, anxiety, or psychosis sought consultation, and only a third of those with alcohol and drug addiction reported seeking help. The first port of call was above all the PCP, except for psychotic disorders, where 60 percent had gone to a psychiatrist. Another 60 percent said they had sought help from friends and family and in 64 percent of cases they had seen an improvement, while 40 percent had taken medication, and 68 percent of them had seen an improvement in their condition (Table 1).

Table 1

Types and effectiveness of treatment and support for individuals with at least one disorder on the MINI—MHGP survey. MHGP national sample

% used% improvement/discontinuation
Friends and family60.964.3
Alternative medicine23.655.5
Religious support2.460.9
Traditional healing2.157.5

Types and effectiveness of treatment and support for individuals with at least one disorder on the MINI—MHGP survey. MHGP national sample

37 Table 1 shows that most remedies are satisfactory, but this is not the case for everyone. It would be interesting to see whether or not these forms of support have a cumulative effect, and whether there is a gradation from asking friends and family for help to hospitalization when community support is not enough. And hospitalization itself was considered effective in only 60 percent of cases.

38 These figures are a local illustration of the pyramid developed by the World Organization of Family Doctors (WONCA) and WHO for mental health care (Figure 2).

Figure 2

WHO pyramid of service organization describing the optimal mix of mental health care services

Figure 2

WHO pyramid of service organization describing the optimal mix of mental health care services

39 With reference to the MHGP survey described above, and to represent it in a different way, we can see that the most important needs are informal care, community care, and self-help, followed by primary health care services, then community psychiatric services, and finally, for a small number of people, hospitalization and long-term hospital stays, for which the level of need is very low and the costs very high.

40 Self-care consists of all care not provided by health professionals, and self-health is the lifestyle adopted to preserve health. Self-care includes the work of the GEM, mutual support, and patient emancipation movements: a more general social movement to combat all forms of discrimination, and demands for social and civil rights.

41 The tripartite foundation of peer support consists of self-care, self-health, and acknowledging the value of experiential knowledge.

42 From these observations, the concept of citizen psychiatry was developed in this particular psychiatry service in northern France, which later developed into the “mental health and citizenship” movement. [25]

The principles of citizen psychiatry

43 There are four principles:

  1. “Being partners, not having partners.” The best application of this in France is the conseils locals de santé mentale (CLSM, local mental health boards).
  2. Hospitalization as an alternative to care in the community. Forty percent of staff work in the community, and sixty percent in hospital. [26] If the majority of staff are based in hospital and the vast majority of patients are in the community, the care system will not work for prevention and hospitalization will be used as a solution, due to a lack of community care. Yet in 60 to 80 percent of cases, the majority of psychiatric staff are still based in hospital. Unless the ratio of hospital/non-hospital staff between the community and the hospital is inverted, community psychiatry, and the focus on prevention, will be merely wishful thinking.
  3. On the patient’s doorstep: this involves the development of mobile teams providing at-home care for both acute and long-term conditions. Wherever these have been introduced, there has been a very sharp decline in the number and length of hospital stays. Home hospital care is one of the services provided by these teams. Their work is based on the principles of immediate availability on request, and the ability to provide frequent care (up to two home visits per day, and even more if necessary). [27]
  4. Service user autonomy: corresponding to the slogan of American service user associations, “nothing about us without us.” It is represented here by the GEM and health peer mediators. The 2002 and 2005 Acts introduced service user participation into the operation of care services in France.

The organization of psychiatric care in the community

44 If all of this is put into place, the shift of the psychiatric hospital into the community becomes effective by integrating all patient services into the community setting. Community caseloads are larger, and the response to citizens’ care needs will be much more effective.

45 Working with the environment means preserving social and family ties, as well as supporting caregivers. It involves recognizing the essential role of caregivers in improving the prognosis of individuals with mental disorders. It helps prevent disruption to care by creating favorable conditions for access to care. PCP are constantly involved in care, taking part in joint consultations, and receiving regular written updates from the psychiatrist taking care of the patient. It also involves working in collaboration with pharmacists to dispense medication, and with independent community nurses to dispense medication at home.

Immediate access to care for all

46 In the spirit of the Alma-Ata Declaration, the Lille experiment has put PCP on the front line of mental health care, with public psychiatrists not supposed to see any patients unless they have previously been seen by their PCP. Most minor disorders can in fact be managed by PCP. If they do need to prescribe a specialist consultation, they do so by liaising with the psychiatry service, and the patient has an immediate formal initial assessment with a psychiatric nurse. Nurses are increasingly skilled in France, and “clinical” nurses perform a high-quality initial assessment within forty-eight hours according to the ISO standard. Their ability to see patients as a first line of care should be highlighted.

47 Integrated, destigmatized psychiatric care has also led to the closure of the centres médico-psychologiques (psychiatric care facilities, CMP) in their old form, and to the opening of consultation and initial assessment facilities in ordinary places in the community: in primary care offices, regional community support centers (UTPAS), social work centers (CCAS), and sports medicine offices. Again, this prevents the reproduction of an asylum model in the community by using a network of mini “psychiatric” institutions.

Availability and flexibility

48 These are the prerogative of the mobile teams. In England, the implementation of mobile teams throughout the country has been very impressive, both for acute care and for long-term integrated community care. It is not enough to simply find housing for psychiatric service users—teams are also needed to follow up with and support them on an ongoing basis.

49 There are also “alternative to hospitalization” foster families, with whom patients are able to stay for a period of ten to fifteen days. Foster families provide full-time care for service users in collaboration with nurses and psychiatrists providing outpatient care, with very positive results in terms of recovery. Some people cannot remain at home during their care because of their isolation or problems with their own family. Foster care is an excellent solution to these problems, and is paid for by the hospital.

Hospitalization founded on rights

50 This care system does still require hospital beds, but these have been moved to non-specialist locations closer to the community: in our case, for example, from the former specialist psychiatric hospital to the general university hospital.

51 The “Jérôme Bosch” Clinic (the term “clinic” is preferred over “hospital” for the purposes of destigmatization), which provides hospital care for all the patients from the service area, has ten beds (compared to three hundred, thirty-five years ago) for a population of over eighty-five thousand. Weekly caregiver-care recipient meetings are run by health peer mediators in conjunction with service users. The facility is not locked and there is no use of seclusion and where possible no restraint. In the rare cases where restraint has to be used, it is reported as an adverse event and subject to a morbidity and mortality review. When the treatment contract offers rapid alternatives to hospitalization, patients accept hospital treatment much more readily. There is no revolving door phenomenon, with fewer patients being readmitted to hospital than in other service areas: hospitalization should not be seen as a prison in which “patients” are locked up. It is therefore an open service regardless of how patients are admitted: under voluntary psychiatric care, involuntary psychiatric care at the request of a third party (SDT), or involuntary psychiatric care at the request of a state representative (SDRE). The average hospital stay is very short (seven days) thanks to the intervention of the mobile teams, who work in close collaboration with community services.

Steps taken by the community psychiatric service to promote service user empowerment

52 A number of actions to promote the empowerment of service users and caregivers have been implemented in partnership in the community itself:

  • The integration of health peer mediators into psychiatric teams has been a remarkable experience. Their work draws on mobilization of their experiential knowledge. They run the service user forum in the community, which enables service users to express their opinions on the care provided, and participate in caregiver-care recipient meetings at the hospital. They provide access to care, chaperoning, emotional support, and patient education in conjunction with other personnel (such as nurses, psychiatrists, and psychologists).
  • Mutual support groups (GEM): these are run by service users themselves, in a model that should be rolled out throughout France. Families are well represented throughout France, in particular via UNAFAM, which gives caregivers a voice, but there is a need for more service users to participate in CLSM and to ensure representation in hospital services, in the division and departmental boards. The GEM could provide the participants required for this health democracy. There are two groups in this experiment, managed by service users themselves. They are represented in all of the service’s decision-making bodies.
  • Division boards and the quality approach: service users and caregivers are integrated into these bodies at all levels.
  • Information sheets on conditions, management, care pathways, rights, and how to obtain direct access to records are distributed to all service users.
  • Being partners, not having partners is the essential principle of empowerment and citizenship. This involves bringing together all the partners in mental health—including psychiatry—in local committees that are chaired by regional elected representatives. This is the case of the Conseil intercommunal de santé, santé mentale et citoyenneté (CISSMC, Intercommunal Council on Health, Mental Health, and Citizenship), which includes all the towns covered by the service, is chaired by a local elected official, and brings together all of the people concerned by psychiatry from the health, social, justice, policing, and other sectors.

53 The strategic objectives of the CLSM are to implement mental health observation, enable access to and continuity of care, promote social inclusion, help fight stigmatization, and promote mental health in the community.

54 In terms of practical actions, the CLSM for the service area described in this article has allowed public psychiatric facilities to be set up in non-specialist locations, and has provided 170 housing units over thirty years, enabling any patients who remained in hospital due to lack of housing to be discharged (which did, however, require the creation of mobile teams for their continued follow-up). It has implemented all the awareness-raising and destigmatization campaigns in the community, and has worked with service users to provide information about mental health conditions at the local level. When politicians and the public take up the issue of mental health, we see how effective it can be in increasing access to rights and care for all.

Evaluation of the integrated care program

55 The evaluation of activity between 1971 and 2013 (Table 2) shows that in this service, which treats all types of disorders under all types of care (including involuntary), there are almost no hospital beds, no patients are homeless, and all those who need it have been rehoused by the local authorities. The structure of care activities has changed considerably. Today, sixty thousand outpatient consultations take place in conjunction with PCPs, and there are very few days of hospitalization. Mental health staff enjoy working in this new organization of psychiatry and mental health in the community.

Table 2

Change in the activity of the 59G21 service since 1971

Agora (access to housing and Maison A.
Artaud – CMP)
A. Breton (facility for people with psychological
and mental disabilities)
Short-term treatment foster familiesIntensive community care team – GEMCISSMCEstablished the general hospital (Lille CHRU)
Number of people receiving treatment5897359781 6771 8982 5722 799
Number of hospitalized people145392287359284261231
Number of hospital beds2921723426261210
Duration of hospital stay (in days)±21313325,714,512,46,57,5
Average number of hospital staff35018529191277
Outpatient care: number of procedures02 7838 13923 47825 00848 31560 461
Proportion of staff working in the community1%10%49%59%69%73.2%72.5%
Table 2

Change in the activity of the 59G21 service since 1971


56 Lucien Bonnafé’s message, which has now become that of WHO, to always put people before walls, has been particularly effective. It has been accompanied by a perspective and paradigm shift from imposed, prescribed care to new relationships between service users and the care and support system. It has also required major anthropological and sociological change, repositioning care for the individual, for the person in the broadest sense, by affirming their free choice and active contribution to their treatment plan. It also repositions people with mental disorders as people who can recover, participate in their care and reintegration, and remain active citizens. [28]

57 This requires a radical transformation of psychiatric institutions, which must move from a hospital-centered system to a diversified, multi-partner system of care in the community, always working on prevention, in connection with basic health and social services. The key is, of course, to integrate service users and caregivers into the operation of these services.

58 All of these goals—moving from hospital-based governance to shared governance in the community, involving all of the health and social integration actors across the territory, but also residents, citizens, patients, and caregivers—can be achieved within the framework of the CLSM. In France, the CLSM can be said to represent the prototype of the application of the WHO mental health principles. All of the ingredients to establish this new order exist in France, but will they be backed up by the will to make it happen?


  • [1]
    Lucien Bonnafé (Figeac, October 15, 1912–March 14, 2003) was a French anti-alienation psychiatrist who, in conjunction with others, developed and implemented community psychiatry in France.
  • [2]
    WHO, Primary Health Care: Report of the International Conference on Primary Health Care, Alma-Ata, USSR, 6–12 September 1978 (Geneva: WHO, 1978).
  • [3]
    The First International Conference on Health Promotion, Ottawa, November 17–21, 1986.
  • [4]
    Jacques Hochmann, Pour une psychiatrie communautaire (Paris: Le Seuil, 1971).
  • [5]
    WHO, Mental Health Action Plan 2013–2020 (Geneva: WHO, 2013).
  • [6]
    WHO, European Mental Health Action Plan 2013–2020 (Geneva: WHO, 2013).
  • [7]
    Denys Robiliard, “Rapport d’information déposé en application de l’article 145 du Règlement par la Commission des affaires sociales en conclusion des travaux de la mission sur la santé mentale et l’avenir de la psychiatrie,” Assemblée Nationale, 2013.
  • [8]
    Patrick Le Cardinal, “Les pairs-aidants ou médiateurs de santé-pairs: enjeux d’un nouveau métier dans le champ de la santé mentale,” Pluriels 85/86 (2010): 3–5.
  • [9]
    Recommendations for empowering mental health service users and caregivers. Translator’s note: The following is our translation. Unless otherwise stated, all translations of cited foreign language material in this article are our own. Protection of fundamental rights:
    • 1. Ensure the protection of fundamental rights in care and rehabilitation institutions.
    • 1a. Ensure these rights are enforced, and put in place a system of sanctions for violations.
    • 2. Guarantee the self-determination and legal capacity of service users and caregivers.
    • 3. Defend the full citizenship of service users and caregivers.
    • 4. Empower service users and caregivers to choose their own care and rehabilitation professionals.
    • 5. Record seclusion and restraint practices, with a view to restricting them.
    • 6. Evaluate practices involving involuntary care, with a view to limiting them.
    • 7. Develop care services as close as possible to where people live and promote alternatives to hospitalization.
    • 8. Promote legal and judicial support for service users and caregivers, including incarcerated individuals.
    • 9. Guarantee access to mental health care in prison.
    Participation in the organization and evaluation of care:
    • 10. Establish the effective participation of service users and caregivers at all levels by guaranteeing the conditions for its application.
    • 11. Evaluate care quality, the organization of services, and patient safety using tools developed in conjunction with service users and caregivers.
    • 12. Incorporate service user and caregiver input into initial and continuing education modules for mental health professionals, and into research.
    • 13. Promote organized prevention at the local level involving service users, caregivers, professionals, social workers, elected officials, and civil society.
    • 14. Give service user and caregiver organizations a place in mental health services.
    • 15. Develop mutual support networks and groups.
    Information and communication:
    • 16. Provide access to appropriate mental health information in a range of different media, including written media, images, films, social media, and blogs.
    • 17. Provide access to international human rights conventions and treaties applicable to mental health service users.
    • 18. Provide access to the available data on current service provision and the need for mental health services in the local area.
    • 19. Create an observatory for service user and caregiver empowerment, including an international database of evaluation tools.
    • 20. Create media watch groups for coverage of mental health, and encourage service users and caregivers to respond.
    • 21. Recognize the experiential knowledge of service users and caregivers and promote it to citizens and health professionals.
      Available online at
  • [10]
  • [11]
  • [12]
    William A. Anthony, “Recovery From Mental Illness: The Guiding Vision of the Mental Health Service System in the 1990s,” Psychosocial Rehabilitation Journal, 16, no. 4 (1993): 11–23.
  • [13]
    Equal Rights and Opportunities, Participation and Citizenship of Disabled People Act of February 11, 2005 (Act no. 2005-102, JO no. 36 of February 12, 2005, page 2353).
  • [14]
  • [15]
    Longitudinal studies in support of recovery: Bleuler (1972), Ciompi (1976).
  • [16]
    Marianne Farkas, Center for Psychiatric Rehabilitation, Boston University.
  • [17]
    Michael Rowe et al., “Going to the Source: Creating a Citizenship Outcome Measure by Community-Based Participatory Research Methods,” Psychiatric Services 63, no. 5 (2012), doi: 10.1176/
  • [18]
    Sherry R. Arnstein, “A Ladder of Citizen Participation,” JAIP 35, no. 4 (July 1969): 216–24.
  • [19]
    Michel Manciaux and Jean-Pierre Deschamps, La Santé de la mère et de l’enfant (Paris: Flammarion, 1978).
  • [20]
    Jean-Luc Roelandt and Patrice Desmons, Manuel de psychiatrie citoyenne: L’avenir d’une désillusion (Paris: Éditions In Press, 2002).
  • [21]
    Act no. 2002-303 of March 4, 2002, on the rights of patients and the quality of the health care system.
  • [22]
    Jean-Luc Roelandt, La démocratie sanitaire dans le champ de la santé mentale. La place des usagers et le travail en partenariat dans la cité. Rapport remis au ministre délégué à la santé par le docteur Jean-Luc Roelandt (Paris: Ministère de Santé, 2002). Available at:
  • [23]
    Imane Benradia, “Enquête Santé Mentale en Population Générale, site du secteur 59G21. Rapport pour le Conseil Intercommunal Santé, Santé Mentale et Citoyenneté, Ronchin,” November 2011.
  • [24]
    Antoine Lazarus, “Intervention au DIU Santé Mentale communautaire: étude et applications,” Sainte-Anne, January 2014.
  • [25]
    Jean Luc Roelandt et al., “Community Mental Health Service: An Experience from the East Lille, France,” Journal of Mental Health and Human Behaviour 19, no. 1 (2014): 10–18.
  • [26]
    France’s national mental health support task force devoted its January/February 2011 letter “Pluriels” (no. 87/88) to the local mental health boards:
  • [27]
    Marianne Ramonet and Jean-Luc Roelandt, “Soins intensifs à domicile: modèles internationaux et niveau de preuve,” Annales médico-psychologiques 171, no. 8 (2013): 524–30.
  • [28]
    “Madness”—not people, psychiatry, the “insane,” or “patients”—is continually on trial here, for in this experiment, madness returns to the community and once again becomes a political problem. In the nineteenth century this problem had been resolved by moral treatment and confinement being provided in the same place, the psychiatric asylum. Now that the asylum and moral treatment no longer exist, these functions are back where they belong: confinement in prison, and patients in the community. The problems of stigmatization and exclusion henceforth arise in the community, as the asylum can no longer mask them. The “trial of madness” must be permanent in order to flush out new forms of social exclusion under the pretext of “madness,” “mental illness,” and mental disability. The breeding ground for stigma has not disappeared with the institution, but has moved and repositioned itself in the field of politics. It is therefore up to politicians to deal with it.

The general principle underpinning the work of the World Health Organization (WHO) is to “think globally, act locally.” This article considers the main founding WHO texts that determine the orientations of its mental health policy, which is based on three concepts: empowerment, recovery, and citizenship. The conceptual framework for the implementation of these three concepts is community mental health. Finally, we illustrate these policy orientations using the specific example of integrated mental health services in the eastern suburbs of Lille.

  • citizenship
  • patient rights
  • empowerment
  • health organization
  • community psychiatry
Jean-Luc Roelandt
figure im1
Jean-Luc Roelandt is a psychiatrist and the director of the French World Health Organization Collaborating Center for Research and Training in Mental Health (WHOCC)
Anaïs Vaglio
Anaïs Vaglio is a former psychiatry resident at the WHOCC
Justine Magnier
Justine Magnier is a chief resident at the WHOCC
Laurent Defromont
Laurent Defromont is the division chief of the Lille-Métropole EPSM (Public Mental Health Facility)
This is the latest publication of the author on cairn.
This is the latest publication of the author on cairn.
This is the latest publication of the author on cairn.
Uploaded on on 04/11/2022
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