Institutional language and quality of life in the French medico-social field: from discursive governance to practice-with-many framework

Abstract

Background

Institutional discourse shapes how care, autonomy and participation are governed within the French medico-social field for autistic people and individuals with intellectual disabilities. Although the Quality of Life (QoL) paradigm is prominent in policy documents, little is known about how its dimensions appear in the everyday language of service organisations. This study examines how institutional communication frames inclusion and support, and how these discursive patterns align with or diverge from multidimensional QoL models.

Methods

We analysed a national corpus of 4,813 publicly available service charters (projets de service) from French medico-social organisations. A mixed-methods design was used: (1) computational topic modelling with Latent Dirichlet Allocation to identify latent thematic structures; and (2) qualitative interpretive analysis to examine how autonomy, rights, participation and support are semantically framed. Interpretation followed the multidimensional QoL framework, focusing on material, bodily, relational and psychological domains.

Results

The topic model revealed a coherent discursive configuration centred on project-based care, developmental rationalities and symbolic commitments to inclusion. Across the corpus, psychological, relational and developmental dimensions of well-being dominated, while physical, material and socio-economic aspects were consistently marginalised or rendered implicit. This imbalance indicates a partial translation of the QoL model, privileging relational and developmental ideals over embodied and material conditions of daily life.

Conclusions

Institutional language reproduces a selective interpretation of QoL, emphasising relational and psychological components while underrepresenting bodily, material and socio-economic domains essential to everyday well-being. Drawing on institutional psychotherapy and disability studies, we propose the notion of practice-with-many (pratique-à-plusieurs) as a collective, reflective counter-model capable of reintroducing embodiment, dependence and shared vulnerability into the governance of care. QoL emerges as a situated, relational and institutional construct shaped by everyday service practices rather than solely by policy frameworks.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13690-026-01967-3.

Text box 1. Contributions to the literature
• Shows how institutional language in disability services can partially translate Quality-of-Life frameworks, privileging relational and psychological ideals while sidelining bodily and material conditions
• Demonstrates the value of large-scale computational text analysis for making visible the normative assumptions that govern inclusion, autonomy and participation in medico-social systems
• Proposes the “practice-with-many” framework as a concrete way to reconnect Quality-of-Life agendas with embodied vulnerability and shared clinical reflection, offering public health actors a tool to reorient services toward more situated and materially grounded forms of inclusion

Background

Over the past twenty years, the promotion of well-being and inclusion for people with intellectual disabilities has become a priority in major international political and scientific agendas [1–4].

At the same time, this apparent consensus has been accompanied by persistent frictions, theoretical disagreements and debates, and no stable agreement has been reached on how inclusion and well-being should be conceptualised and operationalised. Institutions such as the World Health Organization (WHO) and the European Union explicitly recognise that the full exercise of citizenship rights for people with disabilities must be grounded not only in appropriate healthcare and welfare measures, but above all in paradigms centred on self-determination, social participation, and the removal of material, social, and cultural barriers [1, 3, 4].

The WHO [1] highlights the need for all welfare systems, including health and social services, to adopt integrated and fully inclusive measures that ensure accessibility, personalisation of services, and the active role of users in decisions that directly affect them.

In parallel, the European Strategy for the Rights of Persons with Disabilities 2021–2030 [3] identifies key objectives such as deinstitutionalisation, the promotion of independent living, non-discrimination, and full access to services, emphasising the need to move beyond a purely clinical-diagnostic perspective towards a multidimensional understanding of well-being and quality of life. These tensions are not only theoretical but also institutional, and they become visible in the ways policies and services are discursively framed and implemented.

The concept of quality of life (QoL) occupies a central place in these developments. It has become an important reference in policy and medical contexts [5–7], but it has also been the object of substantial debate and critical examination in disability studies. From the perspective of the social model of disability [8–10], structural and environmental barriers—rather than individual quality of life—are the primary analytical focus, which makes QoL a situated and multifaceted construct rather than a neutral metric. As a result, many researchers in disability studies, medical sociology and anthropology have critically examined QoL, questioning its normative assumptions and political implications (e.g. [11]) and highlighting how QoL frameworks can both enable and constrain the implementation of rights [12].

Recent work in disability and crip studies has further stressed that QoL cannot be disentangled from broader political and economic conditions [13–15]. Austerity policies and neoliberal forms of governance have been shown to disproportionately affect people with disabilities, reshaping the distribution of resources and the temporal organisation of care [13–18]. Rather than treating the marginalisation of material and socioeconomic conditions as a simple discursive omission, these approaches invite an analysis of how economic pressures shape what is foregrounded and backgrounded in policy and institutional texts. In this context, the notion of “crip time” highlights how dominant expectations of linear, regular, productive and predictable time are tied to ableist and capitalist imperatives, while disabled and neurodivergent temporalities are often discontinuous, fluctuating and difficult to reconcile with institutional rhythms [13–15]. Empirical work in autism research [19–24] has used this lens to show how academic and educational routines, expectations of developmental progress and productivity norms can clash with autistic temporalities, reframing “delay” or “slowness” as a form of mismatch rather than deficit. Complementary studies on the quality of life of autistic people [19–21, 25–29] underline the limitations of generic QoL instruments, often insufficiently sensitive to subjective, contextual and temporal dimensions of autistic lives.

In light of the central role of QoL in disability policies and service governance, this analysis draws on the multidimensional conceptualisation proposed by Schalock and Verdugo [30–33]. Its relevance for policy-makers and service providers makes it a pragmatic lens for analysing the evaluative language of institutional governance. Importantly, and despite broader debates, the model's non-pathologizing focus on domains like self-determination, social inclusion, and rights offers a framework attentive to individual trajectories relevant for for clinical-organisational practices. Consequently, and in line with critical disability studies, we treat QoL not as a self-evident truth but as a flexible analytical framework that can help to move beyond strictly medical or functionalist understandings of disabled people’s lives. The QoL criteria are therefore mobilised as a heuristic grid to illuminate institutional material and to reveal which domains are foregrounded, muted or displaced in the discourse, without prejudging its meaning or standardising its interpretation.

Specificities of the French context

In France, the regulation and provision of services in the field of intellectual disability, particularly with regard to autism, have evolved along a trajectory marked by tension between historically medicalised approaches and the increasingly explicit adoption of the rights-based and social inclusion paradigm [34, 35]. The 2005 law pour l’égalité des droits et des chances, la participation et la citoyenneté des personnes handicapées (Loi n°2005–102 du 11 février 2005) represents a turning point, while still drawing upon elements of the medical model that continue to shape institutional language, practices, and governance [36].

French service charters (projets de service) reflect the widespread adoption of the projet individualisé/personnalisé as a transversal organisational framework (ITEP, IME, SESSAD, experimental structures), structured around personal development and autonomy, with differentiated implementations according to the type of service and the users’ age. However, recent scientific analyses [37–40] and reports from the UN CRPD Committee [36] highlight persistent critical issues: the fragmentation of services, the delayed attention to material and bodily dimensions (housing, accessibility, physical well-being), the limited valorisation of users’ voices, and a tendency to administer rights through bureaucratic procedures rather than through everyday practices of empowerment.

Furthermore, the strong associative governance model produces considerable variability in the actual implementation of self-determination and individualised support principles, exposing users to territorial disparities and inconsistencies in access to resources [39, 41]. Several studies and policy analyses [34, 35, 39, 41] document how disability service governance in France is profoundly influenced by the presence of associations and local actors, often resulting in significant territorial variability in the application of self-determination principles and in the provision of individualised support. The works of Baudot [39], the Ministère chargé de l’Autonomie et des Personnes handicapées [42], and comparative European analyses by Roleska et al. [43] and Bunt et al. [44] document the internal fragmentation, disputes, and resistance within the French system, including controversies surrounding autism and the difficulty of ensuring real consistency across territorial and institutional contexts. Crucially, these dynamics cannot be understood in isolation from the contemporary political economy of welfare. In a context of budgetary constraints and increasing managerialisation, the politics of austerity actively shape these institutional struggles, ultimately determining the concrete possibilities for self-determination and participation available to disabled people [16–18]. The literature [45] therefore calls for a shift towards more integrated and person-centred models, capable of genuinely including the plurality of experiences, vulnerabilities, and material needs. Although the French medico-social system is historically and institutionally specific, the tensions it embodies—between rights-based rhetoric and material constraints, between autonomy as an ideal and dependence as lived reality— echo challenges documented in other welfare systems facing austerity-driven reforms and managerial governance of disability services [16–18, 46]. In the context of the EU Strategy for the Rights of Persons with Disabilities [3] and related funding instruments, which increasingly rely on QoL-oriented criteria to guide service development and evaluation — as exemplified by both the DIS-QOL project framework [47] and its empirical outcomes on self versus proxy rating of quality of life [48] and the development of operational tools such as the Quality-of-Life Impact Assessment Tool (QIAT) under the Erasmus + QOLIVET project [49] — we therefore treat the French case as a strategic site for examining how QoL-based and rights-based agendas are discursively implemented in contemporary disability services.

The centrality of autism and inclusive practices

Autism has long occupied a central position in international and European debates on disability policies, compelling institutions to reflect on the adaptability and innovativeness of the services provided [43, 44]. French and European strategies converge on the need to promote personalised and multidisciplinary interventions in which autistic people are active protagonists and service design becomes a participatory and flexible process, also in response to the criticisms raised against exclusively clinical and diagnostic approaches [3, 50–52].

Despite normative advances and the widespread adoption of instruments such as the projet de vie, the scientific literature [37, 40, 50, 53] reveals the persistence of exclusionary dynamics, the marginalisation of bodily and material dimensions, and a structural difficulty in implementing genuinely inclusive practices, both in educational and social contexts. Specifically, Guillemot et al. [37, 53] document the challenges of fully integrating autistic children within school environments, while ethnographic studies [40, 50–52] and research on the French university system [54, 55] underline the insufficiency of standard accommodations and the persistence of stigma. Recent sectoral literature [40, 44] also identifies the limited distribution of material resources (e.g., housing, transport, reception facilities) and the undervaluation of corporeality as key obstacles to effective inclusion. These material and attitudinal barriers are compounded by a normative conflict rooted in ableist conceptions of time. Research demonstrates [15, 20, 23] that institutional rhythms, developmental milestones, and productivity demands often fail to accommodate autistic temporalities. This systemic dissonance resonates with critical analyses of crip-time [13, 14], which conceptualise such conflicts not as personal failings but as a fundamental misalignment between neurodivergent ways of being and the hegemonic, able-bodied pacing of social and institutional life.

The quality of life of people on the autism spectrum therefore depends profoundly on their recognition as rights-bearing subjects and agents of change, rather than as mere recipients of services [50, 56].

Research gap and objectives

Internationally, Quality-of-Life (QoL) frameworks have become a key reference for evaluating disability policies and services, and for operationalising the rights recognised in instruments such as the CRPD, particularly through multidimensional models that link individual outcomes to environmental and systemic conditions [5–7]. At the same time, critical disability and crip scholars have shown that QoL is a contested and situated construct, whose domains are shaped by austerity, neoliberal governance and ableist temporal norms rather than simply reflecting “objective” well-being [11, 13–15, 23]. A growing number of studies apply QoL frameworks to assess service effectiveness, to monitor outcomes and to guide person-centred planning in disability services [5, 12, 57]. Yet, to our knowledge, there is almost no research that systematically examines how QoL is discursively mobilised in institutional documents such as service charters and projets de service, and how this shapes the governance and legitimation of disability services.

In the French medico-social field, a substantial body of scholarship has analysed disability policy, governance and inclusive practices, with particular attention to autism and intellectual disability [34, 37, 39–41, 44, 50, 53–55]. However, few studies have systematically examined how institutional discourse itself articulates, legitimises, or constrains the implementation of rights-based and QoL-oriented paradigms across the medico-social sector [34, 39, 58, 59]. Existing research tends to privilege either macro-policy analysis or ethnographic perspectives on service delivery, leaving the linguistic and normative texture of institutional documentation—such as service charters and projets de service—largely unexplored. As a result, we still know little about how QoL domains are selectively translated, prioritised or muted in the texts that govern disability services, and how this selective translation may reproduce the very tensions between rights, material conditions and temporal norms that international debates have identified [7, 13–15].

Moreover, while the projet individualisé and projet de vie are now central to the organisation of medico-social care in France, their discursive functions—as vehicles of empowerment, regulation, or symbolic compliance—remain insufficiently theorised and empirically mapped. This study addresses these gaps by analysing a large corpus of official service charters (projets de service) produced by French institutions in the intellectual and developmental disability sector. Through computational text mining and topic modelling, it seeks to identify the underlying thematic structures that shape institutional representations of care, inclusion and autonomy, and to examine how these structures align with or depart from multidimensional QoL frameworks.

Specifically, the research pursues three objectives: (1) to uncover the recurrent semantic and normative patterns that define contemporary French medico-social discourse; (2) to interpret these patterns through a multidimensional QoL framework [33–45, 50–56, 58, 59], thereby linking linguistic regularities to conceptual dimensions of well-being, rights and participation; and (3) to discuss how the observed configurations reveal both advances and blind spots in the discursive translation of inclusion and QoL agendas into institutional language. In doing so, the article contributes to a broader international debate on the textual governance of disability services, and positions corpus-based computational analysis as a methodological interface between disability studies, policy discourse and clinical-institutional practice in contexts where QoL is used to legitimise and fund disability provisions, including but not limited to the French medico-social sector.

Methods

Dataset and context

The dataset analyzed in this study comprises a systematically organized collection of official service charters (“Service Projects”) freely available on the websites of institutions that provide support to people with mental disorders throughout France. This textual corpus was compiled as part of a funded Erasmus + cooperation partnership project which covers three countries: France, Belgium, and Italy. However, in this work, we will focus on analyzing data from France, leaving the correlational analysis between the three countries for another publication. The aim here is therefore to map the discursive and normative landscape of service provision to people with disabilities, and more specifically to people with autism spectrum disorders, in the French medico-social sector.

Relying primarily on publicly available reference materials, institutional websites, and archival sources, the data collection process prioritized comprehensiveness and representativeness, ensuring the inclusion of founding documents from the institutional contexts of organizations that care for people with autism spectrum disorder: therapeutic, educational, and pedagogical institutes ITEP-Instituts Thérapeutiques Éducatifs et Pédagogiques), medical-educational institutes (IME-Institut Médico-Educatif), specialized education and home care service (SESSAD-Services d’Éducation Spéciale et de Soins à Domicile), and Experimental or Polyvalent Establishments dedicated to persons with disabilities.

Each charter delineates the organizational principles, service offerings, rights, and procedural guarantees underpinning institutional activity in the disability field. Together, they provide insight into both the regulatory framework and the everyday practices shaping access to care, education, social participation, and autonomy for disabled persons. Notably, the experimental and polyvalent establishments included in the corpus reflect evolving models of person-centered care, often combining residential, occupational, and health-related interventions and, in some cases, piloting innovative services under temporary funding schemes.

For this analysis, the corpus was intentionally segmented into four distinct subgroups, corresponding to each institutional type, in order to facilitate nuanced comparisons and to address the substantial heterogeneity both in document structure and target population. The resulting dataset includes over n4813 unique charter texts collected in 2025, with each document undergoing a rigorous quality check to ensure completeness and legibility. While the institutional focus introduces certain thematic constraints—privileging texts that conform to regulatory and administrative conventions—the diversity of providers and service models guarantees the presence of a wide array of discursive registers, policy stances, and rhetorical strategies.

From a methodological perspective, this dataset is particularly suited to unsupervised topic modelling. The charters span a continuum from highly formalized legalese to narrative-rich expository sections and case illustrations, thereby offering fertile ground for the identification of both dominant and latent themes. Rather than imposing stringent a priori filters based on document length, content keywording, or service subdomain, the sampling strategy prioritized inclusiveness, seeking to capture the full spectrum of symbolic and procedural language characteristic of French disability services.

Such heterogeneity, though analytically demanding, underpins the exploratory ethos of the present research—aimed at surfacing not only shared discursive patterns but also the subtle institutional distinctions that shape the experience of disability in the contemporary French context. By foregrounding both compositional diversity and methodological transparency, the resulting corpus stands as a robust substrate for topic modelling and qualitative inquiry alike.

Pre-processing and methodology

The present study draws on a uniquely structured textual corpus composed of service charters (Projets de Service) issued by a range of French institutions supporting individuals with mental disabilities. This collection encompasses documents from Instituts Thérapeutiques Éducatifs et Pédagogiques (n1666 ITEP), Institut Médico-Educatif (n639 IME), SESSAD (n2170 Services d'Éducation Spéciale et de Soins à Domicile), and both experimental and polyvalent establishments (n338). These are diverse settings, spanning from therapeutic-educational centers and multidisciplinary outpatient services to semi-residential or experimental venues organized as innovative living spaces. All documents examined in this analysis articulate legal, ethical, and procedural frameworks by which disability-related services are delivered in France. Given both the substantial scale and heterogeneity of the corpus—as well as the exploratory emphasis on recurrent thematic patterns—a robust and replicable pre-processing pipeline was implemented using KNIME 5.4.4. Analytics platform.

Data pre-processing

The pre-processing phase was designed to systematically transform a heterogeneous set of service charters into thematically tractable input for topic modelling. The corpus, which consists of documents issued by multiple institutional types specializing in intellectual and developmental disability services in France, was first segmented into four institution-specific subsets (ITEP, IME, SESSAD, and experimental/polyvalent establishments). This segmentation was driven by computational considerations as well as the desire to capture potential variations in thematic structure across service models. Each subset was subsequently processed using an identical workflow to ensure analytic comparability and methodological transparency.

Textual preparation commenced with the ingestion of raw documents via KNIME’s file reader. Initial filtering excluded empty or malformed lines, while a dedicated string cleaning phase targeted encoding errors and anomalous symbols introduced by legacy file formats or OCR processes. This involved the systematic removal of non-UTF-8 artifacts and stray punctuation, as well as the explicit filtering of problematic tokens—such as percent signs, ampersands, and other non-alphabetic marks—that could otherwise introduce undesired noise into the analytical lexicon. All content was then converted to lowercase to standardize lexical representation and conform to best practices for token matching.

Recognizing the limited coverage of standard French stopword lists in handling administrative or legal texts, we combined KNIME’s built-in French stopword filter with an expanded, custom dictionary curated from well-established external resources (github.com/gillesbastin/french_stopwords). This dual strategy ensured comprehensive exclusion of functional words and high-frequency but non-discriminative terms.

To further enhance lexical homogeneity, texts were subjected to stemming using KNIME’s French Snowball Stemmer, reducing word forms to their morphological roots and thus mitigating the risk of topic fragmentation due to orthographic or grammatical variation. Punctuation erasure operated in parallel, ensuring the removal of residual symbols that persisted after stopword filtering and stemming. The resulting normalized documents were vectorized via a bag-of-words approach, and immediately following vectorization, a rule-based row filter was applied to exclude short, numeric, or non-alphabetic tokens, supporting the goal of producing a semantically dense term-document matrix.

The complete preprocessing pipeline, built and executed in KNIME, is illustrated in Fig. 1. This figure encapsulates the sequential logic of the multi-step cleaning, normalization, filtering, and modelling process as implemented for all data subsets. By rigorously standardizing the preprocessing workflow and explicitly documenting all parameter choices, we balanced computational feasibility with maximum preservation of thematic and discursive richness, a prerequisite for robust and transparent topic modelling.

Fig. 1.

KNIME workflow used for data preprocessing and topic modelling. Each node corresponds to a specific step in the pipeline, from Unicode normalization and string cleaning to bag-of-words creation and LDA topic extraction

To further enrich and triangulate the interpretation of textual patterns, supplementary lexical analyses were performed using Voyant Tools. The word cloud visualization of the entire data corpus (Fig. 2) provides a complementary lens on the lexical salience and co-occurrence patterns identified in the topic modelling process. As a descriptive corpus profile obtained via Voyant Tools, the dataset contains approximately 1,987,284 tokens and 42,742 unique word forms (vocabulary density = 0.022), with an average sentence length of 33.3 words. The word cloud was generated using the Cirrus tool, displaying the 125 most frequent terms after stemming and filtering with the French stopword list.

Fig. 2.

Word cloud visualization of the 125 most frequent terms in the corpus, generated with Voyant Tools

Topic modelling

Upon completion of the preprocessing sequence, topic modelling was conducted independently for each subset of the corpus, leveraging KNIME’s Topic Extractor (Parallel LDA) node. For each collection of service charters—segmented by institutional typology—a document-term matrix was constructed via the Bag of Words Creator. This vector representation formed the backbone for subsequent unsupervised topic extraction.

The LDA models were parameterized to identify two dominant topics per subset, balancing model interpretability with the data volume characteristic of each institutional category. For each topic solution, the top ten weighted terms were retained in order to define thematic cores and facilitate downstream qualitative interpretation. The number of algorithmic iterations for Gibbs sampling was set at 1,500, a threshold identified in pilot testing as sufficient for convergence without excessive computational overhead. Key hyperparameters were likewise specified: alpha was set to 0.2, anticipating moderately distributed topic allocation across documents, while beta was fixed at 0.01 to yield more sharply delineated topic-word distributions indicative of thematic focus. To maximize replicability and consistency across experiments, a fixed random seed was employed throughout.

While alternative modelling frameworks—such as neural embedding-based approaches—are increasingly available, standard LDA retains advantages in contexts where reading, interpretability, and cross-corpus comparison are paramount. Given the institutional specificity of each subcorpus, LDA offered a robust and transparent framework for exploratory theme detection, with topic-word assignments that could be readily contextualized within both the policy language and service-specific discourse of each institution.

Each topic solution was subject to close semantic inspection, whereby the top-ranking terms were reviewed and provisional thematic labels were manually assigned. While these theme labels are necessarily interpretive and dependent on researcher expertise, they provide a transparent heuristic for guiding further qualitative analysis and for mapping variation in discourse structures across institutional types.

Ethical considerations

The corpus under analysis is composed exclusively of publicly available institutional documents—service charters formally published by French medico-social organizations supporting persons with intellectual and developmental disabilities. Given the public and non-identifiable nature of these texts, no direct informed consent from individuals was required, nor were issues related to personal privacy implicated.

Nevertheless, the sensitive context of disability services necessitated heightened ethical awareness. Our team ensured full compliance with French and European data protection norms, including the General Data Protection Regulation (GDPR), by maintaining strict safeguards around data storage, access, and anonymization of any potentially sensitive client or staff information inadvertently embedded in the texts.

Given that the study focuses on aggregate discursive patterns and not on individual behavior, and that the data do not include any sensitive personal information, formal ethical approval was not required.

This study followed the STROBE reporting guidelines for cross-sectional studies (see Supplementary material for the checklist).

Results

Extracted topics

The Latent Dirichlet Allocation (LDA) modelling yielded eight distinct topics distributed across the four institutional subcorpora. Each pair of topics corresponds to one category of service charter—SESSAD, IME, établissements expérimentaux et polyvalents, and ITEP—and reflects a specific configuration of language and meaning within the medico-social field. While all subsets converge around the organizing principle of the projet personnalisé (individualized plan), they differ in how they articulate care, coordination, and inclusion.

The following sections present each pair of topics in detail, summarizing their most salient terms and outlining the thematic orientation that characterizes the discourse of each institutional type.

1. Topic 0 – “Child-centred care and individualized support within family-professional networks.”

   Top-weighted terms include service, l’enfant (the child), jeune (youth), professionnels (professionals), famille (family), besoins (needs), suivi (follow-up), and projet (project). The lexical constellation reflects an integrated discourse of accompaniment (accompagnement), in which children and families are positioned at the heart of service provision, supported by multi-professional teams who ensure continuous suivi (monitoring) and adjustment of interventions to identified besoins (needs). The presence of social underscores the transversal dimension of inclusion and participation, situating SESSAD not merely as therapeutic or educational entities but as agents of social integration.

2. Topic 1 – “Collaborative practice and co-construction of the life project.”

   Dominated by projet, enfants (children), professionnels, travail (work), parents (parents), personnes (persons), and vie (life), this topic expands the semantic field of intervention toward coordination and collective engagement. The emphasis on travail (work) and professionnels suggests a focus on teamwork, inter-disciplinary dialogue, and partnership with parents. The frequent occurrence of vie and projet points to the projet de vie (life project) as both a normative and aspirational frame, through which services seek to enhance autonomy, quality of life, and long-term inclusion for children and their families.

   Together, these two topics delineate the main discursive architecture of SESSAD charters: a movement from personalized care and educational accompaniment toward collaborative, project-based coordination that connects individual trajectories to broader institutional and social frameworks.

3. Topic 2 – “Professional mediation and life-project orientation.”

   The first topic emerging from the IME (Instituts Médico-Éducatifs – Medico-Educational Institutes) corpus is dominated by terms such as personnes (persons), projet (project), vie (life), professionnels (professionals), jeunes (youth), handicap (disability), travail (work), and services (services). This lexical constellation delineates a discourse centred on professional mediation and institutional structure. The IME appear as spaces where multidisciplinary professionnels coordinate around the projet de vie (life project) of jeunes en situation de handicap (young people with disabilities). The recurring presence of personnes and services reinforces the relational and systemic nature of the institutional mission, positioning IME as intermediaries between individual trajectories and collective welfare infrastructures. The reference to travail (work) points to both internal coordination within the professional team and the preparatory dimension of vocational orientation—bridging education and future autonomy.

4. Topic 3 – “Youth development and goal-oriented pedagogy.”

   The second topic is strongly characterized by jeunes (youth), professionnels (professionals), vie (life), projet (project), besoins (needs), objectifs (objectives), place (place), and ans (years). This configuration conveys a pedagogical discourse centred on developmental progression and individualized goal-setting. The combination of besoins and objectifs indicates a procedural alignment between the evaluation of needs and the definition of measurable learning or behavioural targets. Meanwhile, place and vie evoke a broader ethical concern with social belonging, the “place” of young people in everyday life and community contexts. The lexical recurrence of ans suggests a developmental temporal framing: age and maturation function as both organizational categories and normative benchmarks for intervention. Collectively, these elements portray IME as institutions that scaffold personal growth through structured, goal-oriented pathways integrating therapeutic, educational, and social dimensions.

5. Topic 4 – “Temporal coordination and shared responsibility in youth support.”

   The first topic emerging from the corpus of établissements expérimentaux et polyvalents (experimental and polyvalent establishments) is characterized by recurrent terms such as jeunes (youth), projet (project), travail (work), service (service), temps (time), charge (responsibility or care), professionnels (professionals), and prise (taken in charge or care provision). This lexical field reflects a procedural discourse centered on temporal coordination and shared responsibility in youth accompaniment. The combination of travail, service, and professionnels indicates a collaborative framework where multiple actors contribute to the prise en charge (care and support) of young people across time. The prominence of temps signals the importance of duration and continuity, emphasizing follow-up (suivi dans le temps) as a structural component of these services. In contrast with the more standardized medico-educational institutions, these establishments appear to valorize processual flexibility, allowing interventions to evolve dynamically through time and across professional boundaries.

6. Topic 5 – “Interdisciplinary service networks and inclusive practice.”

   The second topic, with dominant terms such as jeunes, projet, service, professionnels, vie (life), personnes (persons), enfants (children), and besoins (needs), extends the semantic field of care into an interdisciplinary and inclusive register. The consistent recurrence of personnes, enfants, and vie situates the institutions within a continuum of life-course support, bridging childhood and adolescence while addressing diverse developmental besoins. The co-occurrence of projet and service reiterates the logic of the projet individualisé (individualized plan) but within a more fluid, network-based organizational model. The presence of professionnels across both topics reinforces the centrality of professional cooperation, yet in this context it conveys a sense of horizontal partnership rather than hierarchical delegation, suggesting that experimental establishments function as micro-systems of innovation within the broader medico-social field.

7. Topic 6 – “Institutional frameworks and associative governance of youth projects.”

   The first topic emerging from the ITEP (Instituts Thérapeutiques, Éducatifs et Pédagogiques – Therapeutic, Educational and Pedagogical Institutes) corpus is characterized by the high frequency of projet (project), service, association, jeunes (youth), établissements (establishments), and œuvre (work or institution). This constellation reflects the dual nature of ITEP discourse, which oscillates between institutional governance and educational accompaniment. The recurrent mention of association and œuvre points to the associative structures that manage most ITEP in France, highlighting their hybrid identity, simultaneously administrative and community-based. The co-occurrence of projet and service situates the institutional mission within the logic of the projet thérapeutique et éducatif personnalisé (individual therapeutic and educational project), an instrument that formalizes the coordination of interventions across care, education, and social inclusion. The emphasis on jeunes and enfants anchors this administrative discourse in the concrete reality of child and adolescent development, framing the ITEP as both regulatory entities and relational spaces where institutional missions are enacted through pedagogical practice.

8. Topic 7 – “Therapeutic accompaniment and the temporal dynamics of care.”

   The second topic, defined by recurrent terms such as jeunes (youth), enfants (children), travail (work), vie (life), temps (time), besoins (needs), projet (project), and professionnels (professionals), foregrounds the therapeutic and temporal dimension of the ITEP mandate. The prominence of temps and vie suggests an understanding of intervention as a longitudinal process of transformation, where travail thérapeutique (therapeutic work) unfolds across multiple temporalities: daily rhythms, developmental milestones, and institutional cycles. The interplay between besoins and projet reveals a discourse that negotiates between individualized attention and structured planning, while professionnels underscores the role of interdisciplinary teams (psychologists, educators, social workers, and therapists) in sustaining continuity and coherence over time. Collectively, this topic articulates a model of accompagnement thérapeutique (therapeutic accompaniment) that intertwines affective, pedagogical, and social dimensions within an evolving relational framework.

   To strengthen the interpretive validity of our topic modelling outcomes and to offer an accessible visualization of lexico-discursive salience, we generated a word cloud with 125 terms using Voyant Tools (see Fig. 2). The visual prominence of terms such as projet^(10575), jeunes⁽⁶⁴³⁹⁾, service⁽⁶¹⁴⁰⁾, professionnels⁽⁵⁸⁰⁵⁾, enfants⁽⁵³⁷²⁾ in the word cloud closely aligns with the lexical cores identified in our computational analysis, suggesting a high degree of convergence between unsupervised thematic extraction and basic frequency-based lexical profiling. This triangulation provides additional confidence in the consistency of emergent themes and offers an immediate, reader-friendly entry point into the discursive landscape of the corpus.

Exploratory interpretation

The dual thematic configuration identified in the SESSAD corpus reveals a consistent narrative of accompagnement global, a holistic model of care articulated through the interdependence of individualized support and collective coordination. Topic 0 embodies the micro-relational dimension of service delivery, where the enfant (child) and famille (family) are engaged through an individualized process of suivi (follow-up) managed by professionnels (professionals). This configuration reflects the person-centred ethos of French disability services, in which the recognition of besoins (needs) constitutes both the ethical and procedural foundation of intervention. The language of monitoring and project formulation signals a bureaucratic yet affectively charged discourse, one that balances regulation with empathy, and standardization with personalisation.

By contrast, Topic 1 situates the same logic of care within a broader ecosystem of collaboration. Here, the projet de vie (life project) functions as an integrative metaphor through which institutions, professionals, and families co-construct shared objectives, blending administrative rationality with participatory ideals. The lexical prominence of travail (work), parents (parents), and personnes (persons) underscores a collective orientation, suggesting that SESSAD charters frame inclusion not only as an outcome but as a process of negotiated partnership. The convergence of projet and vie anchors this discourse in a developmental temporality, linking educational and therapeutic interventions to the child’s broader trajectory toward social citizenship.

Taken together, these two topics articulate a continuum of care that oscillates between the intimate and the institutional, between individualized accompaniment and collaborative governance. This discursive architecture mirrors the dual mandate of SESSAD services: to provide responsive, child-centred support while fostering networked practices that enable long-term autonomy and inclusion. From a broader interpretive standpoint, the model captures how the language of “project” operates simultaneously as an administrative tool, a relational practice, and a symbolic horizon of empowerment within the French medico-social landscape.

The two topics extracted from the IME corpus articulate complementary aspects of institutional discourse: professional coordination and pedagogical individualization. Topic 2 reflects the IME’s structural function as mediating institutions within the medico-social continuum. The prominence of professionnels, personnes, and services anchors the text in a bureaucratic vocabulary of organization, responsibility, and procedural clarity. Yet the co-occurrence of projet, vie, and handicap re-humanizes this framework, translating administrative routines into relational acts of accompaniment. The projet de vie operates as a symbolic interface between individual aspiration and institutional rationality, allowing the professional network to articulate care not only as a technical obligation but as an ethical commitment to personal flourishing.

Topic 3, conversely, exposes the pedagogical grammar that structures everyday practice within IME. The dense clustering of jeunes, objectifs, and besoins signals a discourse of developmental intentionality: interventions are conceived as progressive sequences designed to transform needs (besoins) into achievements (objectifs). The term place encapsulates the dual goal of education and social participation, suggesting that inclusion is both a spatial and moral endeavour, ensuring that each jeune finds a meaningful position (place) within society. This semantic field resonates with the educational principle of accompagnement éducatif personnalisé (personalized educational support), central to the medico-educational ethos in France.

Together, these topics frame the IME as institutional laboratories of normalization and empowerment, spaces where professional coordination and individualized pedagogy intersect to produce subjects capable of social participation. The discursive balance between procedural precision and affective engagement mirrors a broader tension within French disability policy: the pursuit of autonomy through structured dependence. Within this linguistic architecture, the projet de vie emerges again as a key mediating concept, bridging institutional accountability and personal development across temporal and relational scales.

The two topics identified in the corpus of experimental and polyvalent establishments articulate a discourse of temporal adaptability and collaborative inclusion, marking a distinct evolution within the French medico-social landscape. Topic 4 foregrounds the management of time (temps) and the coordination of travail (work) as key organizing principles. Here, prise en charge (care provision) is not conceived as a fixed institutional function but as an ongoing process, negotiated, distributed, and redefined through the collaborative travail of professionals over extended periods. The temporal vocabulary (e.g., temps, suivi, continu) underscores a conception of intervention as a continuum, blurring the boundaries between short-term educational goals and long-term trajectories of autonomy. This configuration reveals a pragmatic reorientation of care: from stability and structure toward mobility and responsiveness, reflecting the experimental mandate of these establishments to test flexible, person-centered methodologies.

Topic 5, by contrast, highlights the networked and participatory dimension of these institutions. The semantic clustering of jeunes, enfants, personnes, and vie articulates a holistic vision of inclusion that transcends age categories and disciplinary silos. Rather than operating through a single institutional logic, these services mobilize interdisciplinary assemblages, teams that integrate educational, therapeutic, and social expertise around the projet individualisé. The emphasis on besoins (needs) reaffirms the ethical imperative of responsiveness, while the consistent appearance of professionnels points to a redefinition of expertise itself: from vertical authority to distributed competence within participatory care networks.

Taken together, these topics portray experimental and polyvalent establishments as laboratories of temporal and relational innovation, where care is simultaneously adaptive and co-constructed. Their discourse reconfigures institutional temporality—not as linear progression but as cyclical negotiation—while extending the notion of inclusion beyond physical access to encompass relational belonging and interprofessional solidarity. This evolution from procedural rigidity to discursive flexibility mirrors broader policy shifts in the French medico-social field [60, 61], where innovation expérimentale serves as both a regulatory framework and a symbolic marker of institutional transformation. Through annual calls for project-based experimentation and derogations from standard funding rules, the medico-social sector is being reconfigured not only in terms of practices, but also in its underlying discourse of care and inclusion.

The two topics derived from the ITEP corpus encapsulate the institutional and therapeutic dialectic that defines this segment of the medico-social system. Topic 6 captures the organizational grammar through which ITEP articulate their mission, emphasizing projet, association, and service as the administrative scaffolding of therapeutic and educational practice. The recurrence of associative terminology (association, œuvre, établissements) situates ITEP within France’s long-standing tradition of gestion associative, where public mandates are implemented by semi-independent non-profit structures. This governance model infuses the discourse with a civic ethos, presenting care as both a social duty and a collective enterprise. The projet thérapeutique et éducatif thus emerges as an instrument of governance and a symbol of accountability, translating the moral commitment of the association into measurable institutional action.

Topic 7, in turn, unfolds the ITEP’s therapeutic philosophy, which intertwines structure and fluidity through the management of temps (time). The terms vie, besoins, and travail reveal a temporalized understanding of intervention, one that recognizes instability, rupture, and recovery as inherent components of development. Here, travail thérapeutique is conceived less as treatment and more as a form of accompanied becoming, where professionals and young people co-construct trajectories of change within the safety of institutional continuity. The relational density of this discourse underscores the importance of temporality not only as an operational parameter but as a therapeutic condition: stability is cultivated through repetition, predictability, and sustained presence.

Together, these two topics reveal the ITEP’s distinctive position at the intersection of education, therapy, and governance. The projet functions as the institutional pivot linking administrative rationality and relational care, while temps serves as its existential axis, mediating between the immediate demands of behaviour management and the long-term aspirations of personal autonomy. This dual orientation toward structure and duration exemplifies the broader cultural logic of the French medico-social field, where therapeutic intervention is both bureaucratically codified and profoundly humanized.

Unified interpretation: institutional discourses and the dimensions of quality of life

When examined as a whole, the eight topics identified across the four institutional subcorpora (SESSAD, IME, établissements expérimentaux et polyvalents, and ITEP) reveal a remarkably coherent discursive ecosystem. Beneath the surface diversity of terminologies and mandates, a shared semantic structure emerges, one that articulates the ethos of the French medico-social system through the recurrent motif of the projet (project). Whether designated as projet personnalisé, projet de vie, or projet thérapeutique et éducatif, this concept functions as both a managerial technology and a moral grammar of care. It simultaneously organizes institutional activity and legitimizes it through reference to individual autonomy, participation, and social belonging. Table 1 summarizes this interpretive synthesis, mapping each topic onto the multidimensional Quality-of-Life framework developed by Schalock and Verdugo [5–8]. The table serves as a visual heuristic, highlighting how institutional discourses privilege certain domains of well-being while marginalizing others.

Table 1.

Mapping of extracted topics to the eight Quality-of-Life domains

Institution	Topic (#/label)	Emotional well-being	Physical well-being	Material well-being	Personal development	Self-determination	Interpersonal relationships	Social inclusion	Rights
SESSAD	0 – Child-centred care & individualized support	H	L	L	H	M	H	M	M
SESSAD	1 – Collaborative practice & co-construction of the life project	M	L	L	H	H	M	H	M
IME	2 – Professional mediation & life-project orientation	M	L	L	H	M	M	M	M/H
IME	3 – Youth development & goal-oriented pedagogy	M	L	L	H	H	M	M/H	M
Établissements expérimentaux/polyvalents	4 – Temporal coordination & shared responsibility	M	L	L	H	M/H	M	M/H	M
Établissements expérimentaux/polyvalents	5 – Interdisciplinary service networks & inclusive practice	M	L	L	H	M	H	H	M
ITEP	6 – Institutional frameworks & associative governance	M	L	L	H	M	M	M	H
ITEP	7 – Therapeutic accompaniment & temporal dynamics of care	H	L	L	H	M	H	M	M

This table cross-references the eight topics identified through LDA modelling with the eight domains of Quality of Life proposed by Schalock and Verdugo (Schalock & Verdugo, 2002, 2012, 2021; Verdugo et al., 2012). Salience levels (H = High, M = Medium, L = Low) indicate the relative prominence of each domain within the discursive structure of institutional charters. The table highlights the predominance of relational and developmental dimensions—personal development, self-determination, interpersonal relationships, and social inclusion—and the relative underrepresentation of material and physical well-being

Qualitative rationales for the salience ratings:

SESSAD-0: enfant, famille, suivi, besoins → strong interpersonal + personal development; emotional supported by continuous accompaniment

SESSAD-1: projet de vie, parents, travail d’équipe → high self-determination (co-construction), strong social inclusion, sustained personal development

IME-2: professionnels, personnes, services, projet de vie → robust personal development; rights/accountability moderated by institutional mediation

IME-3: besoins, objectifs, place, ans → high personal development + self-determination (goal-setting); social inclusion via place

Établissements-4: temps, travail, prise en charge → adaptive personal development; self-determination/inclusion through temporal coordination

Établissements-5: professionnels, personnes, enfants, vie → strong interpersonal + social inclusion; personal development via interdisciplinary integration

ITEP-6: association, œuvre, établissements, projet thérapeutique et éducatif → high rights (governance/accountability) with solid personal development

ITEP-7: temps, vie, travail thérapeutique → high emotional well-being + interpersonal; sustained personal development over time

This shared “project logic” can be interpreted as the discursive correlate of the Quality of Life (QoL) framework articulated by Schalock & Verdugo [30–33], whose eight domains—emotional well-being, physical well-being, material well-being, personal development, self-determination, interpersonal relationships, social inclusion, and rights—offer a multidimensional matrix for assessing the coherence and completeness of support systems for persons with disabilities. When read through this lens, the French charters collectively embody an implicit model of QoL promotion, though one that remains unevenly distributed across institutional types and levels of intervention.

Personal development and self-determination

The most prominent dimension across all subcorpora is that of personal development, intertwined with self-determination. The lexical centrality of projet, besoins, and objectifs indicates a procedural concern with individual progress and goal-setting. In the SESSAD and IME contexts, this manifests through personalized educational and therapeutic trajectories that translate developmental psychology into administrative practice. The discourse emphasizes agency within structure: individuals are invited to “co-construct” their path, yet always under professional mediation. In experimental establishments, temps (time) and travail (work) extend this logic toward adaptive methodologies that valorise ongoing negotiation over fixed outcomes, an approach that resonates with Schalock & Verdugo’s understanding of development as a dynamic process of self-actualization [30–33].

Interpersonal relationships and emotional well-being

The domains of interpersonal relationships and emotional well-being surface primarily in the relational vocabulary of famille, parents, personnes, and accompagnement. The SESSAD corpus, in particular, foregrounds these affective and communicative ties, positioning the family as both beneficiary and partner in the projet personnalisé. The recurrent emphasis on suivi (follow-up) points to the moral dimension of care as continuous presence and relational trust. Within IME and ITEP texts, this interpersonal orientation assumes a therapeutic form, where stability, predictability, and repetition are framed as prerequisites for emotional security. Such configurations align with Schalock & Verdugo’s notion of well-being as relational reciprocity: care not as a service delivered, but as an ongoing dialogue between dependence and recognition [30–33].

Social inclusion and rights

A second transversal axis concerns social inclusion and rights, dimensions that underpin the participatory rhetoric of all institutional charters. Terms such as vie (life), place (place), and participation (often embedded within the broader discourse of inclusion sociale) articulate a moral geography of belonging. The institutions are portrayed not only as spaces of treatment or education but as gateways to community life, mediating between the private sphere of the family and the public sphere of citizenship. In this respect, SESSAD and experimental establishments stand out as agents of territorial inclusion, promoting itinerant and networked forms of intervention that bridge institutional and social boundaries. Yet, the emphasis on administrative procedures (service, établissements, association) reveals that rights are often operationalized through bureaucratic codification rather than emancipatory practice, what might be termed a regulated inclusion. This discursive duality mirrors Schalock & Verdugo’s observation that social inclusion requires not only access but empowerment, not only participation but influence [30–33].

Physical and material well-being

By contrast, the dimensions of physical and material well-being are only marginally visible in the corpus. References to handicap and services evoke the structural conditions of access to care, yet rarely engage with the material determinants of daily life, housing, income, or bodily health. The charters’ institutional focus privileges the symbolic and relational over the corporeal and economic, reinforcing a cultural pattern where disability is conceptualized primarily as a pedagogical or psychological condition rather than a socio-material one. From a QoL perspective, this lacuna signals a potential blind spot in French medico-social discourse: the risk of overlooking the infrastructural aspects of well-being that underpin genuine autonomy.

Rights, governance, and accountability

The final dimension, rights, appears most clearly in the ITEP corpus, where associative governance and the projet thérapeutique et éducatif embody a collective commitment to civic responsibility. The language of association, œuvre, and établissements translates rights into duties, reframing the citizen’s entitlement as an organizational obligation. This managerial ethics of care aligns with Schalock and Verdugo’s conceptualization of rights as an ongoing process of implementation, whereby organizations translate abstract principles into measurable and accountable practices [32, 33]. Here, the French model exhibits both strength and fragility: while the associative tradition safeguards ethical pluralism and local responsiveness, it also disperses responsibility, rendering rights contingent upon institutional interpretation.

A composite model of quality of life

Synthesizing these patterns, the French medico-social discourse, as captured through the charters, articulates a composite model of Quality of Life. It privileges the relational and developmental dimensions—personal development, self-determination, interpersonal relationships, and social inclusion—while underrepresenting the material and physical aspects of well-being. Across all institutional types, the projet operates as a symbolic anchor, binding together bureaucratic coordination, therapeutic care, and ethical aspiration. The result is a vision of inclusion as relational citizenship: a mode of belonging grounded in accompaniment and in procedural participation.

In this sense, the topic modelling reveals not only the structure of institutional discourse but also the ideological architecture of the French medico-social system itself, a system that aspires to humanize governance through care, yet remains haunted by the paradox of dependency within empowerment. Interpreted through Schalock & Verdugo’s multidimensional lens [30–33], the corpus suggests a nation deeply invested in the moral economy of support, but still negotiating how to translate the promise of quality of life into the material and political realities of disabled persons’ everyday existence.

Discussion

From discourse to practice: institutional language as a site of clinical governance

The results show that the projet individualisé operates not merely as an administrative tool but as a central discursive technology within what can be read—following [39] – as a bureaucratic form of care. In the French medico-social field, the bureaucratic vocabulary of the projet—accompagner, suivre, co-construire—does not just document care; it shapes subjects and relations. Naming, classifying, and projecting developmental goals establishes a moral order of governance in which care and control are mutually constitutive, legitimising the therapeutic mission while rendering persons with disabilities visible, accountable, and governable within social policy.

This configuration reflects the enduring tension between universalist and personalised approaches that has characterised French disability policy since Loi n°2005–102 [62]: as Winance, Ville and Ravaud [34] note, governance continually negotiates between the universal promise of equal rights and categorical/diagnostic logics; Ravaud and Stiker [63] similarly analyse the ambivalence of expanding rights alongside professional mediation and institutional dependency. Within this dual movement, the projet functions as a key bureaucratic artefact translating political principles into everyday therapeutic and administrative routines [64, 65].

From this angle, the eight domains of Quality of Life [30–33] can be read not only as evaluative categories but as a discursive matrix that articulates a moral economy of care. In the charters analysed, personal development and self-determination dominate, whereas material and physical well-being remain marginal. This selective uptake confirms that QoL frameworks, widely used to steer and evaluate disability services, are not simply “applied” but are selectively translated into institutional language: psychosocial and developmental domains are amplified, while material, bodily and socio-economic domains are consistently backgrounded. This pattern echoes critical disability scholarship on austerity and neoliberal governance [16–18, 66], where rights and participation are discursively foregrounded while redistributive and embodied dimensions of disability are relegated to the background. QoL thus operates less as a neutral technical model than as a political grammar that defines what can be said, measured and ethically pursued, privileging project-based autonomy and symbolic inclusion over structural support and material redistribution. In this sense, the discourse of quality becomes a form of clinical governance, prescribing desirable subjectivities and embedding ideals of care within bureaucratic rationality and austerity-driven constraints.

In sum, the projets de service stage inclusion, autonomy, and participation as iterative speech acts that institutionalise empowerment while delimiting its practical scope, making visible how QoL-oriented and rights-based agendas are discursively implemented and narrowed within a specific regime of clinical governance.

The paradox of inclusion: between rights discourse and lived embodiment

The corpus evidences a persistent imbalance between the symbolic affirmation of inclusion and limited recognition of embodied and material realities. Inclusion frequently appears as a linguistic ideal – an index of adherence to rights-based frameworks—detached from corporeal, sensory, and economic conditions of daily life. This resonates with post-disability critiques of the cultural denial of vulnerability underpinning Western ideals of autonomy [67]. By construing the disabled subject as a rational, self-determining agent—an ideal participant in the projet de vie – institutional discourse reaffirms independence while relegating dependence, fatigue, pain, and bodily unpredictability to the margins.

This pattern accords with Goodley’s [66] account of dis/ability as a biopolitical formation that simultaneously empowers and normalises: participation and competence are celebrated while the uneven distribution of resources conditioning access to education, housing, or belonging is obscured. In our corpus, “self-determination,” “personal development,” and “participation” encode an ideal of the competent subject compatible with institutional rationality yet distant from lived corporeality. Correspondingly, material and physical well-being—two QoL domains [5–8] – are systematically under-represented.

Rather than reiterating the framework, these findings point to a partial cultural translation of QoL, whereby relational and developmental components are absorbed into the grammar of accompagnement and personalisation, while material and bodily dimensions are attenuated. The outcome is a symbolic inclusion grounded in representation more than redistribution: narratives of care and progress predominate, references to space, resources, and the affective labour of sustaining the body remain scarce. This pattern empirically specifies concerns raised in critical disability and crip scholarship about how QoL discourses can foreground participation and autonomy while leaving structural and embodied conditions under-addressed, and suggests that recognising this paradox does not negate the achievements of Loi 2005–102 or the EU Strategy [3] but calls for practices that re-embed QoL in lived, sensory conditions.

Clinical and relational practices as epistemic counter-models

The analysis highlights the remarkable consistency of the French medico-social field around project-based care, participation, and developmental trajectories. It emphasises personal development, self-determination, relational support and symbolic meaning-making—a configuration that reveals a coherent symbolic order within institutional discourse. Yet, when interpreted through Schalock and Verdugo’s Quality of Life (QoL) framework [30–33], this coherence also exposes the limits, indeed several dimensions remain under-represented — revealing blind spots in both the institutional discourse and its psychodynamic reading (see Table 2 about here).

Table 2.

Distribution of QoL dimensions in French medico-social discourse: symbolic coherence and underrepresentation of embodied and material domains

QoL dimension	Presence	Missing elements
Emotional well-being	strong	affective safety acknowledged, but little focus on stress, embodiment of emotions, psychosomatic vulnerability
Interpersonal relationships	strong	focus on family–professional partnerships; limited attention to peers & community belonging
Self-determination & personal development	very strong	autonomy idealized; limited recognition of healthy dependence & structural limits
Social inclusion	strong	inclusion treated as aspiration/trajectory more than lived, fluctuating experience (exclusion, stigma, belonging)
Rights & citizenship	moderate	rights seen as institutional duty; little exploration of lived ambivalence (shame, empowerment, passivity)
Material well-being	weak	poverty, housing, financial constraints barely addressed
Physical well-being	very weak	minimal focus on the body, fatigue, pain, somatic care, sensory and motor constraints

The corpus, like the institutional charters themselves, thus privileges symbolic and relational dimensions over embodied and material ones. This selective articulation of QoL domains confirms the partial cultural translation of the model within the French context: its holistic ambition [32] is filtered through a linguistic and institutional grammar that valorises autonomy and symbolic participation while attenuating physical, sensory, and economic realities. As Winance [68] and Baudot [39] suggest, this imbalance is not accidental but reflects a structural feature of the French medico-social field, where professional mediation and moral duty have historically framed inclusion as a process of psychic normalisation rather than embodied coexistence.

This finding invites a reconsideration of what “clinical” means in institutional practice. Following the lineage of psychothérapie institutionnelle [69–72], care can be understood not only as an individual therapeutic act but as a collective and reflective space: a process of shared attention to the body, the affective climate, and the symbolic life of the institution. Within this perspective, clinical practice becomes a site of transferenceand co-elaboration, where the professional group itself assumes a containing and interpretive function. The challenge, then, is to move from a managerial rationality—where autonomy is planned and assessed—to a relational rationality, where autonomy emerges through mutual dependence and collective reflection.

The interpretive trajectory emerging from the analysis invites a reconsideration of clinical practice not merely as an applied technique but as an epistemic counter-model to the bureaucratic logic that dominates the medico-social field [73–75]. Within the French tradition of psychothérapie institutionnelle, theorists such as Oury [69] and Guattari [70] have long argued that care must be conceived as a collective, dynamic process—a form of co-presence that redistributes agency and responsibility among all participants in the institutional space. In this lineage, the clinic becomes less a site of correction than one of transference and shared elaboration, where meaning, affect, and embodiment are constantly negotiated. This conception resonates with what Winance [68] later described as pratiques d’accompagnement, relational configurations that re-articulate dependence as a resource rather than a deficit, transforming the act of caring into a shared process of becoming.

Re-reading our results through this lens clarifies the critical distance between the institutional discourse of the projet individualisé—with its emphasis on autonomy, planning, and evaluation—and the lived relationality of everyday care. The project-based framework formalises participation and self-determination, but it also stabilises them within procedural and managerial constraints.

From this angle, the “practice-with-many” (pratique-à-plusieurs) a dispositif developed by Di Ciaccia [76, 77] can be read as both a clinical and epistemic extension of this tradition: an operational form that reintroduces the body, the environment, and shared vulnerability into the field of care. Rather than proposing a new organisational tool, it expands the very notion of the clinic, transforming it into a space of intercorporeal thought. The pratique-à-plusieurs operates precisely where the discourse of the projet individualisé reaches its limit, where affect, fatigue, and material constraints resist procedural translation.

It is therefore on this basis that we wish to propose the practice-with-many as a form of collective clinical work capable of addressing the blind spots revealed by the QoL analysis. This practice not only involves including the autistic person in the institution by making them the main actor in their own life project, but also includes practitioners as active participants in that same project. In other words, the practice-with-many approach allows all stakeholders to become partners with the autistic subject by working toward a shared and concrete goal: supporting autonomy understood as an evolving, relational process rather than an endpoint. We do not claim that the idea of care as collective, relational and embodied is conceptually new—this has been thoroughly developed in feminist, disability and care ethics traditions [78–83]. Our contribution lies in showing how, within a QoL-oriented medico-social field, practice-with-many (pratique-à-plusieurs) operates as a concrete institutional dispositif that reopens space for materiality, dependence and shared vulnerability where the project-based discourse of autonomy reaches its limits.

In this framework, the pratique-à-plusieurs functions as a psychic, social, and embodied device that expands the field of care to include what institutional discourse tends to exclude. It operates through several interdependent dimensions:

1. Reintegrating the physical and material. Within a shared professional space, practitioners collectively recall physical needs (fatigue, pain, sensory overload), material obstacles (transportation, housing, financial support), and structural inequalities that affect daily life. This collaborative awareness prevents a purely psychological interpretation of disability and restores the body and vulnerability to the therapeutic horizon.

2. Sustaining subjectivity through collective reflection. The shared work of thinking multiplies perspectives, mitigates idealisation or over-responsibilisation, and distributes emotional holding across the team. Autonomy thus becomes a process rather than an injunction, and meaning-making remains open and negotiated.

3. Making rights experiential, not administrative. Through everyday interactions, rights become lived, negotiated, and emotionally processed, rather than bureaucratically stated. Citizenship is transformed into an embodied and relational experience.

4. Extending inclusion into ordinary life. Teams reflect on peer relationships, community belonging, and daily participation beyond institutional programs. Inclusion thus becomes situated and social, not merely declarative.

5. Revaluing dependence as developmental. Dependence is recognised as relational and generative, vulnerability as constitutive of humanity, and shared responsibility as a resource rather than a failure—counterbalancing the cultural idealisation of independence.

Toward a situated model of quality of life

Taken together, the Discussion suggests that QoL is best approached as a situated construct, historically, culturally, and institutionally embedded [45]. In the French context, the language of the projet individualisé and the ethos of collective care reframe the eight domains as processes mediated by relation, temporality, and dependence:

• Relation: well-being emerges intersubjectively through accompaniment and shared reflection;

• Temporality: autonomy and participation unfold as trajectories rather than endpoints;

• Dependence: far from negating autonomy, it conditions its very possibility in human coexistence.

Seen in this light, practice-with-many (pratique-à-plusieurs) is the operational translation of this epistemic shift: it turns QoL from a managerial device into a lived, intersubjective, institutional experience, enabling autistic persons, practitioners, and organisations to share responsibility for constructing meaning and well-being—an enactment of relational citizenship rather than a mere evaluative matrix. In contexts where QoL frameworks are used to justify and fund disability services, including within the European policy landscape, this suggests that the key question is not only which QoL model is adopted, but how its domains are discursively translated into institutional texts and complemented by clinical practices capable of re-embedding QoL in embodied, material and temporal conditions.

Methodological limitations

Several methodological limitations inherent to this research design warrant careful consideration. First, the decision to employ Latent Dirichlet Allocation (LDA) for topic modelling—while motivated by its interpretability and established usage in applied policy analysis [84–87] – nonetheless introduces constraints typical of unsupervised probabilistic modelling. LDA assumes that topics are multinomial distributions over vocabulary and that documents are mixtures of such topics; while this framework is robust for exploratory thematic mapping, it can flatten subtle institutional differences or marginalize infrequent but meaningful lexical nuances, particularly in corpora as heterogeneous as service charters for disability provision.

The technical implementation of the pipeline, performed entirely within KNIME, also imposed boundary conditions on analytic scope. The need to restrict each LDA run to two topics per subgroup, dictated by the desire for interpretability, means the thematic landscape described here necessarily privileges dominant discursive frames over rare or emergent themes.

Text pre-processing, while designed to maximize semantic density and comparability, presents its own trade-offs. The combined use of standard and custom French stopword lists, punctuation erasure, stemming, and rule-based token filtering succeeded in removing a substantial volume of noise and context-irrelevant language, yet these procedures invariably risked the exclusion of meaningful idiomatic expressions, legal formulae, or domain-specific markers. Moreover, stemming in French, like in other morphologically rich languages, can conflate lexemes with distinct semantic or contextual functions, occasionally blurring thematic boundaries.

Another set of limitations arises from the structure of the empirical corpus. The charters themselves are institutional artifacts, reflecting both regulatory priorities and the linguistic conventions of administrative communication. As such, they may under-represent the lived realities, experiential narratives, or counter-discourses present in the broader disability community, which could be better surfaced through the analysis of user-generated or ethnographic text sources.

Finally, the interpretive process of assigning thematic labels to LDA-generated topic clusters, while grounded in transparent reading of high-weight terms, inevitably involves researcher judgment. Although this is an accepted practice in mixed-methods topic modelling, it limits the purely inductive status of the analysis and necessitates explicit caveats regarding the provisional and heuristic character of the resulting themes. As a robustness check, we triangulated topic-model results with Voyant’s descriptive metrics (token counts, vocabulary density, average sentence length, and top-frequency terms). This triangulation mitigates concerns that the LDA clusters merely reflect preprocessing artefacts or isolated lexical spikes.

Despite these limitations, the analytic pathway adopted here advances the field by demonstrating how large-scale topic modelling, combined with clinically informed qualitative interpretation, can be used to map systematic patterns in institutional discourse on disability and QoL. This mixed-methods approach does not aim to produce radically new theoretical concepts, but to generate a different kind of evidence about textual governance—showing, at corpus scale, which QoL domains are amplified or muted across thousands of service charters and how this configuration resonates with on-the-ground clinical and organisational practices, in France and in other contexts where QoL is used as a key device for legitimising services.

Conclusions

This study has shown that the French medico-social field articulates a highly coherent moral and linguistic order centred on the projet individualisé, a bureaucratic yet affectively charged dispositif [88] that governs inclusion through the grammar of care, participation, and personal development. By applying computational topic modelling to a corpus of over four thousand service charters, we have demonstrated how institutional discourse functions as both a reflection and a producer of social policy, shaping the very conditions under which rights, autonomy, and subjectivity are enacted.

Interpreted through the multidimensional Quality of Life (QoL) framework [30–33, 45], our findings reveal a systematic privileging of psychological, symbolic, and relational dimensions over the bodily, material, and experiential aspects of well-being. The resulting asymmetry underscores a broader cultural tendency toward what might be called discursive inclusion: the affirmation of rights and participation through language, rather than their full embodiment in everyday life.

Within this landscape, the practice-with-many (pratique-à-plusieurs) emerges as a possible epistemic and clinical counter-model. By reintroducing corporeality, dependence, and shared reflection into the field of care, it offers a situated operationalisation of the QoL paradigm—transforming it from an evaluative tool into an intersubjective and institutional experience. This collective practice expands the clinical horizon beyond managerial rationality, fostering a participatory ecology of care in which autonomy is redefined as a process of mutual regulation, and rights are lived rather than merely codified.

Methodologically, the study demonstrates the value of computational text analysis for mapping the normative textures of medico-social policy, while also acknowledging the epistemological limitations of such an approach: the absence of first-person and experiential voices, and the partial generalisability of findings beyond the French context. Building on established work on institutional discourse and governance, this article advances current debates by specifying how multidimensional QoL frameworks, rights-based agendas and notions of autonomy are selectively translated into institutional language in a QoL-oriented medico-social field. By showing that psychosocial and developmental QoL domains are systematically amplified while material, bodily and socio-economic domains are consistently backgrounded across 4,813 projets de service, the article provides corpus-scale evidence of a partial translation of QoL that makes empirically tangible concerns raised in disability and crip scholarship about the discursive foregrounding of autonomy and participation over structural and embodied conditions [13, 14, 66]. Situated within a French medico-social system that is historically specific yet embedded in the wider European policy landscape—where QoL-based criteria are increasingly used to justify and fund disability services—the case analysed here functions as a strategic site for examining how QoL and rights-based agendas are discursively implemented and narrowed in contemporary welfare systems. In this sense, mechanisms such as the symbolic centrality of the projet and the pattern of “discursive inclusion” speak not only to clinical-organisational debates in France (e.g. [5–7]) but also to broader international concerns about the textual governance of disability services. Taken together, these theoretical and methodological insights invite a shift from viewing QoL as a stable evaluative framework to approaching it as a situated practice that is continuously shaped by institutional discourse and clinical work.

Ultimately, our results invite a reconceptualisation of Quality of Life as a situated construct, inseparable from the cultural and institutional frameworks through which it is enacted. In the French medico-social field, QoL becomes not a universal metric but a relational, temporal, and embodied practice, one that must continually negotiate between symbolic recognition and material reality, between policy and lived experience. The practice-with-many thus encapsulates a broader epistemic imperative: to make the quality of life not only measurable, but shareable, lived, and collectively sustained.

Authors’ contributions

G.T. conceived the study, developed the methodological protocol, contributed to data interpretation, and co-wrote and critically revised the manuscript. M.B. designed and conducted the data analysis, curated the dataset, and drafted the manuscript. P.B. and Y.T. contributed to data collection and provided critical feedback on the interpretation of findings. G.D.C. and M.C. contributed to the interpretation of clinical and institutional practice. G.S. supported project coordination and organisational aspects. D.D., B.R., and S.V. contributed to the contextualisation of the Quality-of-Life framework and revised the manuscript for intellectual content. All authors read and approved the final manuscript.

Funding

This research is funded within the framework of the Erasmus + cooperation partnership project “PIISA” (PIISA-Clinical Practices for the Inclusion of Autistic Individuals inInstitutions) under the coordination of University of Rennes 2 with the participation of Ghent University, Istituto Freudiano and Fondazione Quarto Nodo.

Funded by the European Union. Views and opinions expressed are however those of the author(s) only and do not necessarily reflect those of the European Union or the European Education and Culture Executive Agency (EACEA). Neither the European Union nor EACEA can be held responsible for them.

Data availability

The study analysed publicly available institutional documents (*service charters*) obtained from the official websites of French medico-social organisations. The compiled dataset used for the analysis can be made available from the corresponding author upon reasonable request for academic and non-commercial purposes.

Declarations

Ethics approval and consent to participate

This study did not involve human participants, human data, or human biological material. The research relied exclusively on publicly available institutional documents (service charters) published by French medico-social organisations. In accordance with European data protection law (GDPR, Recital 26), research based solely on publicly accessible, non-identifiable documents does not require ethics committee approval or informed consent. All procedures complied with the ethical principles of the 2013 Declaration of Helsinki.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.