Évaluation d'une action pédagogique dans le cadre de la psychiatrie de liaison

The Anglo-Saxon name of “consultation-liaison psychiatry” points to a bipolarity in the exercise of liaison psychiatry, depending on the fact that the psychiatrist works with the patient (consultation) or with the medical team (liaison). The work with the somatic care team is the specificity of this discipline. But, on the job, the psychiatrist encounters some mistrust and notes some flaws in the training in psychiatric and psychological cares. Based on this remarks, a pedagogical training has been carried out with the somatic cares teams. This pedagogical project aims at (1) improving the knowledge and skills of the trained somatic care team about psychiatrist and psychological aspects of care and (2) decreasing the mistrust triggered by the psychiatrist. According to some authors, liaison psychiatrist is basically a pedagogical procedure. For our study, one service has been chosen. The paramedical team of this service wanted to be more aware of this particular question because it frequently encountered heavy pathologies and end of lives support. Concerning training organization and content, it was composed of four sessions of 1:30 h with four or six persons. Subjects of these sessions were: medical psychiatrist/help relationship/awareness of systemic aspects/when and how work with the liaison psychiatrist? Our training aimed at bringing tools to the somatic care team, in order to take care of the patient as a whole and to improve his suffering resistance. Concerning the methodology, we have chosen a prospective approach dealing with the somatic care team, the patients and the requests for consultations sent to the psychiatrist. As far as the somatic care team is concerned, the following data have been gathered through multiple choices lists that have been proposed to everybody before and after the training: their position in the service/their involvement in the project/their feeling about the help relationship and their collaboration with the liaison psychiatrist/their anxiety level (Spielberger). Regarding the patients, the following data have been gathered through multiple choices lists that have been proposed to every in-patient between February and June 2003: age, sex, pathology/their feeling about psychological consequences of organic diseases and psychiatrist help, with QCM and QO/their anxiety level (Spielberger) and depressive symptoms (Beck). Concerning the calls for consultation sent to the psychiatrist, data collection focus on quantitative and qualitative aspects following the motive for the request. The somatic care team is composed of 25 paramedicals (13 nurses and 12 nurse's aides) and five doctors. Twenty paramedicals have taken part in the training. The somatic care team believes that they have improved their theoretical basis of the help relationship, that they face less difficulties in that relationship, that they better detect the cases where the psychiatrist has to be called for and to improve the preparation of his consultation. The mistrust towards the psychiatry has also decreased. A significant difference has been put forward regarding mistrust-state decrease (Wilcoxon's test, p = 0.004). The multiple choices lists have been proposed to all in-patients, that is to say 100 patients in February and 87 patients in June: 55% of the patients were unable to fill in the form, because of a mental or physical inability, 8% refused to take part in the study, 12% did not give the multiple choices list back because of undetermined reasons, 25%, that is 23 in February and 24 in June, have correctly filled in the form. We did not notice any influence of the training for these patients. An increase in the number of requests for consultation about mixed psychosomatic and somatic problems has been notices. It seems that it is easier to resort to the liaison psychiatrist. We have been able to detect any influence of the training through the patient's self-evaluation. Has the training missed its goal or are evaluation tools not sensitive or specific enough? In this case, let us note that we worked to fulfill the paramedical team request. However, the psychiatrist liaison is not always faced with this configuration. What can be done to make it easier for reluctant somatic care team members to accept more easily the psychiatrist help for themselves and for the patients? To our opinion, it is important to take time for each step of the procedure. Firstly, the integration of the liaison psychiatrist has to be optimized. We must answer the multiple requests and especially those of our colleagues. The target is neither to become recognized, nor to please our colleagues, but to get integrated to play his role: promote a global approach. Secondly, the somatic care team becomes aware of hidden problems. The difficulties are discussed and they must be faced with. The pedagogical action described in this article has to be thought along these lines. The trained somatic care team anxiety decrease tends to prove that they are better prepared to cope with stress. Thirdly, it is high time we started to think. According to the psychoanalytical model, when the subject is faced with a heavy somatic disease, the defense mechanisms can partially decrease the anxiety. These complex psychological processes can modify the perception of the disease and its psychological consequences. A contradiction seems to account for the gap and for the distortion of the psychological system in the situations: 89% of the patients say that they are help in the psychological difficulty by the medical team, whereas 51% say that they have not psychological difficulty. Considerable statistical problems seem to be linked to psychological processes in this kind of study. We recommend a liaison psychiatrist that strives to integrate by answering the somatic care team requests. This integration can favor pedagogical training sessions. We have tried to set up and assess these strategies; the results are globally positive. No improvement can be deduced from the patient's self-evaluation, but considerable statistical problems linked to self-evaluation tools and psychological defense mechanisms can be noticed. Even if these studies are difficult because of an important subjectivity and of a high number of variables to take into account, it is up to us to push forward the analyses and the studies to set up solid bases to deeply root our job.