The expansion of the public mental health care system in France: Interview with Isabel Perera (Cornell University)

There was enormous pressure to reduce public mental health care during the late 20 th century. Part of this pressure came from the movement to “de-institutionalize” people with mental illness out of hospitals and promote their social inclusion. These efforts had good intentions. They aimed to reduce psychiatry’s reliance on hospitals – but deinstitutionalization soon became an excuse of cash-strapped governments to cut spending on mental health care entirely. While all Western countries managed to de-populate mental hospitals this way, only a few were able to expand the non-hospital, community-based services that the deinstitutionalization movement saw as its ultimate goal. That’s where the French case comes in. “La voie française” of deinstitutionalization was different from that of most other countries. France managed to de-populate mental hospitals; but not close them wholesale. Rather, France was one of those few countries to expand non-hospital, publicly funded mental health care, precisely as deinstitutionalization was underway.

While researching French deinstitutionalization, I found that the trade unions representing mental hospitals and related services played an important role in advocating for expansion. They wanted to protect their jobs! What made these unions especially influential, I think, was that they represented a broad coalition of workers across the occupational strata: doctors, nurses, attendants -- and, importantly, service administrators and managers, who often have direct access to policy-makers as their advisees. This coalition lasted for several decades and benefited from several key moments in French political history (e.g., the public employment expansions following May 1968 and Mitterand’s policy settlements of the 1980s). By the late 20 th century, they had managed to increase their job security and, in doing so, expand the mental heath system.

The expansion of French mental health care has led to the “sectorization” system, which seeks to provide a wide variety of public mental health care services (hospital and non-hospital) to geographic catchment areas across the entire territory. The result is a fairly large public mental health care system. Although the system has faced renewed attempts to cut spending in recent years, it remains larger and more comprehensive than those of many other countries.

Where public policies concern public services, they also concern public employees. These workers often are keen to protect these services, especially given tight labor market conditions. Jobs in the public sector are among the most secure and stable in today’s economy. Government workers would like to keep things that way, so they try to increase public funding revenues and bargain for additional job protections.

The spillover effects produce a feedback cycle: in the long run, public sector trade unions work to secure public jobs, which in turn secure public services, ultimately feeding resources back into public unions and empowering them further.

However, this mutually reinforcing feedback cycle is not always morally desirable. Sometimes, public unions can defend services that expand state surveillance or repression beyond what is ethically appropriate (especially an issue in policy or carceral services); or they simply defend services that the public may no longer deem as necessary (e.g., postal work in the digital era). It is important to be sensitive to these risks, particularly since workers have an outsized effect on service provision when client groups lack the political power to demand them (or not) on their own. But in many other cases, public sector trade unions are critical to the maintenance and expansion of valuable public services, such as health care and education.

LIEPP is a wonderful place to work. I especially benefited from the rich expertise of the health policies research group, which provided excellent feedback on my research project. At the same time, I also was able to learn from scholars from the other research groups. This exposure allowed me to both broaden my knowledge of area specialties outside my own while thinking more about our shared theoretical frameworks. Moreover, I very much appreciate LIEPP’s ability to translate top academic research into practice. In my view, this is exactly the task of the policy scholar – but it can be very difficult to do well. Too often, we limit our work to paywalled academic journals and or closed academic conferences. LIEPP, with its emphasis on both Working Papers and Policy Briefs, shows us how to bridge the divide between theory and practice.