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In recent years, the Quebec public health system is gradually being deserted by psychologists, causing a loss of accessibility of their services. At the same time, the notion of a so-called symbolizing and subjectivizing function of the institution is put forward in the context of clinical work with severely affected psychiatric patients consulting on an outpatient basis. However, this function often seems to be attacked by a managerial framework, which could be described as perverse and narcissistic, and which undermines the thought process and creativity of clinicians. Spurred by these ideas, and in resonance with current concerns about the accessibility of psychological services, we propose a reflection on the practice of psychoanalytically oriented psychotherapy within Quebec health care institutions. We draw upon our own experience as young psychologists who have recently left the public system and who have decided to question its underlying principles in an attempt to offer new leads for understanding the current exodus. Our aim is also to move away from financial considerations and focus on the different ways in which the institution no longer serves its original functions, but seems rather to cultivate several forms of destructiveness.

Keywords: réseau public québécois de la santé, exode des psychologues, Institution, psychanalyse, perversion, narcissisme, Quebec public health system, exodus of psychologists, institution, psychoanalysis, perversion, narcissism

AbstractThe majority of studies conclude that the form of treatment therapy provided to the socio-economically underpriveledged clienteles (SEC) are different to those provided to other clienteles. The author says that belonging to a less fortunate SEC is associated to a higher rate of psychological problems; to an "outside" model that seems to influence the expectations vis-a-vis the therapist and the therapy ; and to a perception of the therapist that is probably biaised in part which, in turn, increases the gravity of the diagnosis and influences the manner in which such a clientele is greeted in psychotherapy.

La présente étude porte sur les facteurs déterminants d’une expérience significative en psychothérapie selon la perspective de clients adultes. Les deux principaux objectifs poursuivis dans cette thèse sont : 1) l’exploration et la description des facteurs déterminants d’une expérience significative en psychothérapie selon la perspective des clients; et 2) l’élaboration d’une représentation synthétique et structurée de ces facteurs. Les facteurs déterminants sont regroupés sous sept catégories (Clients, Psychothérapeutes, Relation thérapeutique, Environnements, Impacts, Temps et Investissements) et sous quatre sous-catégories (Corporelle, Émotionnelle, Cognitive et Interactive).

Quebec's HealthCommissioner on the performance of the health system clearly highlighted gaps in the collaboration between primary care physicians and mental health specialists, decreased accessibility and inequity in access to effective mental health services such as psychotherapy.Objectives The aim of this article was to describe the implementation of two publicly funded programs of psychotherapy in Australia and England with similar gatekeeper systems to the one in Quebec.Findings Following the Access to Allied Psychological Services (ATAPS) program introduced in Australia in 2003, one of the most important initiatives from the Council of Australian Governments' National Action Plan on Mental Health 2006-2011 was the Better Access Initiative which commenced in 2006. The plan included AUD1.2 billion in funding for integrating and improving the mental health care system. The purpose of Better Access was to improve the treatment and management of mental illnesses and increasing community access to mental health professionals and providing more affordable mental health care. GPs were encouraged to work more closely with mental health professionals. Under this program, these professionals are able to provide mental health services on a fee-for-service basis subsidized through Medicare. Access to psychological therapies is provided through private providers, rather than through fund holding arrangements. As of 2009 in Australia, 2 million people (1 in 11) had received over 11.2 million subsidized mental health services. A recent study showed clinical improvements in patients with depression associated with Better Access, concluding that the program is meeting previously unmet mental health needs.In the case of England, the IAPT – Improving Access to psychological Therapies-program enabled primary care trusts (PCTs) to implement evidence-based psychological therapies as recommended by National Institute for Health and Clinical Excellence for people suffering from depression and anxiety. In October 2007, the Secretary of State for Health announced additional funds totalling £173 million between 2008 and 2011 that would be used to deliver a major training program that would build a skilled workforce of qualified psychological therapists in 4 therapy areas for adults and children: cognitive behaviour therapy; psychodynamic psychoanalytic therapy; systemic and family therapy; humanistic therapy. The main goals of the program were to have: (i) 3,600 newly trained therapists with an appropriate skill mix and supervision arrangements; (ii) 900,000 more people treated; (iii) 50% of people who leave treatment are recovered; (iv) 25,000 fewer people on sick pay and benefits.Conclusion To date, the results in both countries have shown clinical improvements in symptoms associated with depression and anxiety for people entering the programs and at a population level, decreasing the unmet mental health needs of the population by allowing self-referrals to the program, and therefore rendering access to services to populations otherwise not reached.

Keywords: accès aux services de santé mentale, couverture de santé, programme de santé, psychothérapie, Australie, Angleterre, mental health services accessibility, health coverage, health program, psychotherapy, Australia, England

How is one to understand the power of images, their capacity to signify what “regards” us (Didi-Huberman, 1992)? How can art-mediated psychotherapy respond to the clinical aims guiding the rearrangements of the setting required for certain patients for whom classical analysis is not indicated? Taking into consideration certain points of convergence inherent in the psychoanalytic method, such as it is used in the analysing situation and in mediated psychoanalytic psychotherapy, my remarks centre on the figurative power of words and images and on the psychotherapist's readiness to receive and acknowledge what presents itself in the patient's narrative in verbal or visual form. The case of a patient suffering from a major depression will serve as substantiation in order to show how the implementation of objectivating techniques facilitates the symbolisation work of primary psychic experiences not metabolised up to that point.

Keywords: situation analysante, psychothérapie psychanalytique médiatisée, figuration, associativité, disposition psychique, analysing situation, mediated psychoanalytic psychotherapy, figurative power of words and images, associativity, psychic disposition

Objectives Depressive or anxious disorders are a major source of social and economic burden. Many international good practice guidelines recommend structured psychotherapy for treating depressive or anxious disorders. The positive impact of psychotherapy on health, quality of life, productivity, and on the direct and indirect costs has been widely demonstrated. Nevertheless, the psychotherapies provided in private practice with a non-medical psychotherapist are not reimbursed to patients by French health cover systems.This article aims (1) to assess the cost and benefit of providing a funding program for psychotherapies for the community for French adults suffering from severe or recurrent depressive or anxious disorders, and (2) to estimate the number of psychotherapists that this program would be needed.Methods Data are based on the Enquête Indicateurs de santé mentale dans quatre régions françaises: a cross-sectional survey of a representative sample of 20,777 adults in the general population conducted in 2005. The questionnaires were administered by a telephone interview with the Composite International Diagnostic Interview – short form. A financial evaluation of covering the cost of psychotherapies was performed using the methodology of the British program Improving Access for Psychological Therapies adapted to the French context. The annual cost generated by depressive disorders was estimated at EUR4,702, cost generated by anxiety disorders at EUR1,500. The remission rate attributable to psychotherapies was assessed to be 30% ±10%. The number of sessions to be covered was defined according to clinical guidelines of the National Institute for Health and Clinical Excellence. The cost of a session was estimated at EUR41, the reimbursement rate by the compulsory health insurance system at 60%.Results The yearly cost for the cover of psychotherapeutic care – for 12.1 sessions on average was M EUR 514 (M EUR 308 for the compulsory systems) to treat 1,033M individuals in France, or 2.3% of the population. In terms of the cost-benefit ratio, EUR1 invested in psychotherapeutic treatment could, save from EUR1.14 (0.76-1.52) to EUR1.95 (1.30-2.60) for anxious or depressive disorders respectively.France has the 14,300 professionals qualified to provide the psychotherapies required to treat this population.Conclusion A funding program for psychotherapies proves to be a cost-efficient investment for the community from the short term, for both direct (health costs) and indirect (productivity, quality of life) costs, that is further that the positive impact and costs of psychotherapy on somatic disorders were not taken into account.With a view to providing appropriate care for patients, inter-professional collaboration among GPs and mental health professionals, and between clinical psychiatrists and psychologists, appears essential. These recommendations should be defined in national good practice guidelines.

Keywords: psychothérapies, analyse medico-économique, accès aux services de santé mentale, programme national de santé, économie de la santé, analyse coût-bénéfice utilisation des services de santé mentale, troubles dépressifs et anxieux, France, psychotherapy/economics, community mental health services/supply & distribution, national health programs, policy making, public health/economics, cost-benefit analysis, mental health services utilization, mental disorders, France