Before Prevention
The very notion of prevention encounters a great deal of resistance. It may seem obvious, but the difficulty of overcoming such resistance, the obtuseness of the interlocutors involved to what seem to be quite simple ideas implies that their resistance has a deeper and less circumstantial origin. The resistance of deciders who cannot imagine that a group of professionals might make a proposition without asking simultaneously for more subsidies is something we may accept. For them, the idea that a policy of prevention might actually make it possible to save money must certainly imply a trap hiding something else. But even worse is the resistance to change, questions of identity and territory.
1. Resistance to change: Groups, all groups and their representatives are, by their very essence, conservative, including those who hold firmly to ideas concerning the revolution to come, whatever it might be. Some very complex relations are established between the person who presents a novel approach, the discoverer, the "Messiah" (in the sense used by WR Bion). Of course, this desire for immobility exists in each one of us whether we attribute it to the fear of the unknown, nostalgia for a lost paradise, repetition or death instincts. Changing one medecine for another, one therapeutic treatment for another does not overturn a traditional medical position: the doctor is a fireman who intervenes when, and only when the fire breaks out. He is a repairman for the body and the spirit. In a certain way, intervening beforehand, preventing a disease from manifesting itself (when it might not ever appear anyway) would be close to suicidal. We are familiar with pyromaniac firemen, iatrogenic doctors... but the idea of a fireman with no fires, a doctor without patients or diseases is inconceivable. Not only does the idea of prevention inject a certain amount of anxiety into those who must submit to it, because it is necessary to be worried and to worry people if one wants them to accept preventive measures, but prevention also introduces a malaise concerning the idea which health practitioners have of their work.
2. Medical work is difficult work in which it is always necessary to deal with anxiety: one's own and that of others. Also, the natural tendency which offers partial protection, is to adjust to a territory, a fixed way of doing things where one can feel and perhaps believe that one is in control of the situation. Prevention, though, cannot exist alone. The work of prevention requires the intervention of multiple parameters and various people. It is in the work of prevention that organizational networking (so highly touted in French today, though alas for other reasons) can be carried out with maximum force and clarity. In the field of prevention, the doctor must imperatively share his knowledge but also his uncertainties and his projections for the future. This implies that he is on the tight rope without a net.
3. I don't have to remind anyone here of the importance of work in prevention to lessen the suffering of patients and their families, to reduce the length of treatments and to reduce financial and social costs. Here and there, the interest (and the experiments undertaken) in early detection, early treatment and secondary or tertiary prevention in mental health are recognized. What remains less well-known, little studied and rarely experimented, is primary prevention and the application of the principle of precaution in our domaine. Even though this is the case, many psychiatrists in France realize its importance and its feasability. I will only mention three examples: that of prevention of the effects of aging, primary prevention of suicidal acts, and more particularly, in the framework of an effort that has been carried out for the past ten years in France and which will be detailed in a workshop during the colloquium, that of Information Week about Mental Health which mobilizes many participants and reaches a large portion of the general population.
S.D. Kipman
President, French Association of Psychiatry, Paris
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