[Units for difficult patients in the mental health care system]

[Isolation and restraint in psychiatry: practice and feedback from professional experiences]

A psychiatric nurse since 2013, who became a clinical psychologist in 2022, I have had the opportunity, on numerous occasions, to use isolation and therapeutic restraint as part of my nursing practice, mainly in a closed psychiatric admissions service. These therapeutic tools, specific to psychiatry, are used in a very specific theoretical and legislative framework. Their use always leads to reflection, both individually and as a team. Indeed, their use must remain the last therapeutic bulwark to be used because it can be experienced with difficulty or even in a traumatic way by the patient, which can damage the relationship of trust with the carers. Thus, it is important that this practice be supervised and discussed with the patient and the team in order to be as appropriate as possible.

[Isolation and restraint in units for difficult patients and in psychiatric intensive care units]

The units for difficult patients (UMD) and the intensive psychiatric care units (Usip) are psychiatric services that are not successively sectorized, created to meet the needs of intensive care in a closed environment and sometimes of a forensic nature. These two systems are used to care for patients whose clinical condition often makes it too complex to maintain them in sector psychiatric units, and many of their operating rules differ. This is not the case for seclusion and restraint measures and the application of the law governing these measures.

[Psychiatric care in specially equipped hospital units]

The specially equipped hospital units (UHSA) receive detainees in the region (men, women, minors) requiring full psychiatric hospitalization, either in free care or in care by decision of the State representative. They are located on the site of hospitals, but a penitentiary enclosure allows for the control of the entry and exit of patients, as well as the security of the perimeter. To date, nine UHSAs are in operation in France.

[Health needs and organization of care in prison]

The prison population in France is mostly composed of young but aging men, in relatively good health but vulnerable. In order to ensure optimal health care for this population, several levels of health care organization - somatic and psychiatric - have been set up since 1994. The different structures created since then allow incarcerated patients to benefit from care adapted to their particular conditions.

[Psychiatric intensive care units]

The intensive psychiatric care units are intermediate health structures between the sector psychiatric services and the units for difficult patients. Prisoners can be treated there under article D. 398 of the Code of Criminal Procedure.

[Regional medical-psychological services]

The history of psychiatric care in prisons is relatively recent, and the regional medical-psychological services - initially called regional medical-psychological centers - were established in the different regions of France from 1977 onwards. Their main missions are the prevention and treatment of mental illnesses and addictions, as well as the organization of post-prison psychiatric care. Composed of multidisciplinary teams, they offer individual or group assessments and follow-up, as well as more specific care for certain penal populations.

[Units for difficult patients]

The ten French units for difficult patients are secure psychiatric services which receive people suffering from mental pathologies who could have committed or have committed dangerous acts. Among the mental health structures presented in this dossier, the units for difficult patients are those which admit prisoners with psychological disorders and problems of dangerousness for the longest period of time. As fully-fledged care facilities, they offer intensive and multi-professional care.

[Professional commitment and work in psychiatry]

The practice of care in a psychiatric service, whether outpatient or inpatient, appears more than ever to be a personal commitment. How can we conceive it despite the difficulties of the profession, which make new professionals hesitate to join it? There is now open talk of a "crisis in psychiatry", of professionals leaving the profession. However, many observers and caregivers manage to give meaning to this demanding profession, at the crossroads between disciplines and institutions. The activity is constantly evolving, shaped as much by the advent of multiple theoretical frameworks as by societal movements. The number of people using this discipline, which is now also called "mental health" care, is constantly increasing, while at the same time all the players are struggling to recruit professionals. However, patients who have become users can testify to the quality of the caregivers.

[Management of patients with addictions in units for difficult patients]

The links between mental pathologies and violent acts, which can go as far as homicide, are a major concern for many mental health professionals. Addictive co-morbidities, which are increasingly frequent, are an additional risk factor for some of these patients to commit dangerous acts. Psychiatric and psychological care for pathological perpetrators of such violence can be provided under certain conditions in units for difficult patients, with addiction treatment if necessary.

[Social care for patients hospitalised in units for difficult patients]

The units for difficult patients are secure psychiatric wards that receive mentally ill people who could have committed or have committed dangerous acts. As part of the overall care of these patients, the treatment of their social problems by social workers plays an essential role. These interventions provide the psychosocial benefits necessary for the stabilisation and evolution of these subjects.