Alliance thérapeutique avec les mères et évolution clinique des enfants d'un hôpital de jour

This two-year prospective study in a French child psychiatry day hospital assesses relationship between therapeutic alliance and clinical progress. Thirty-three 3-10 year-old children (18 with pervasive developmental disorders and 15 with mixed behaviour disorders) were assessed regarding their symptom status and developmental progress, while receiving multi modal intervention package. Independently, the treatment staff assessed the therapeutic alliance with the parents by standardized ratings on the French modified Helping Alliance questionnaire from Luborsky. The statistical study shows that a mother's good therapeutic alliance correlate significantly with the social functioning improvement but not regarding the symptom status. As North-American therapeutic alliance adult's studies, this first child psychiatry unit study seems to show that the parent therapeutic alliance is a predictor factor of child outcome independently of age and pathological child status.     

Réflexions sur le cadre thérapeutique et l’institution : médiatisation et caractère partiel

The present epoch is no longer focussed on institutional psychotherapy, but it nevertheless continues to condition clinical practice and is still present in the various institutions in the form of a partially suppressed historical sediment. The present epoch, on the contrary, produces the ‘‘answer’’, provides solutions for reality, fills in for it, and even covers it up. An offer to listen, a project, a protocol, a response, a fantasized ideal bi-correspondence between a problem and its solution, a fantasy that is linked to the development of social discourse appears to be progressively conditioning and directing the organization of the mental healthcare structure. We have used as a basis for this study an aspect that is closely related to the organization of mental healthcare, i.e. the therapeutic approach, to examine the possibility of encouraging respect for the vulnerability of the patient, which, apart from the ethical considerations involved also has its therapeutic implications. We have attempted to define the concept of a therapeutic context in order to analyze it, and have proposed a model based on its partial character. The context is considered both under its ‘‘general’’ aspect (applicable to all) and its specific aspect (the focus being on one subject, or invented by the institution for its sole use). The singular context appears to consist of one that identifies, provides support, can be adapted to the situation and its development, and is interpretative. Moreover, its partial character (the epi-context, which provides support at the institutional level) can be viewed as one that gives the the subject the means to subsequently develop his own context and system of identification (the hyper-context). A representative clinical case has been included to illustrate these hypotheses. Finally, we have postulated that the partial nature of the epi-context provides the patient with the creative space and stimulus necessary to develop the hyper-context, i.e. firstly adjustment, then secondarily a means of establishing his own landmarks, and developing his own context and sense of identity. Thus, the hyper-context can be viewed as a form of open-ended questioning on the nature of the case, that is to say its relation to symbolization.     

Critères de prise de décision aux urgences de l’hospitalisation sans le consentement

In the current context of the new French bill on the rights and protection of persons under psychiatric care, clinical practice in the emergency setting requires that mental healthcare professionals better clarify the criteria they use for the decision of involuntary hospitalization. After defining the concept of consent for treatment and a brief literature review, this study examined the impact of clinical and contextual characteristics on the decision to admit patients whether involuntarily or voluntarily to inpatient psychiatric units. Data was collected from 442 successive patients admitted in hospital for care from five psychiatric emergency facilities in Paris and covered sociodemographic information, previous hospitalizations, recent treatment, clinical diagnosis, Global Assessment of Functioning scale (GAF) and insight measured by the Q8 Bourgeois questionnaire. Patients were also assessed based on criteria established by the French healthcare agency (HAS) for the severity of mental disorders and the necessity of emergency care. Using multivariable logistic regression, diagnosis does not affect the decision of hospitalization. Agitation, aggressiveness toward others, being under the influence of drugs or alcohol, being married or divorced as well as being referred by a doctor are all factors that increase the risk of involuntary hospitalization. Last, low Q8 and GAF scores are strong predictors for involuntary admission. This supports using insight and GAF evaluation in clinical practice for clarifying assessment and decision-making in emergency setting about involuntary hospitalization.     

Expression artistique et médiation thérapeutique

The launch of the Psychopathology of Expression during the last century parallels that of the clinical psychiatry during the XIXth century. Psychopathology of Expression’s main concern is to address the same questions as those raised by the romantism (inspiration, relationship between genious and madness). Artists and physicians simultaneously explore the new cultural entity characterized by the drawings of insane patients. Surrealism, with Dubuffet, will develop its various features leading to the conceptual launching of « Art Brut », the latter will be completely separated from medical science. During the XXth century will turn out from phenomenological to transferencial knowledge through epistemological change. Accordingly from 1950 many art-therapic workshops take place in various sites in France, and mediatized psychotherapies often rely on psychanalytic concepts, as a support to their métapsychological hypothesis.     

Les relations thérapeutiques en psychiatrie hospitalière

Objective

Research has shown a strong association between the quality of the therapeutic relationship and the outcome of psychotherapy. However, there is currently little specific research on the influence of the therapeutic relationship on the various aspects of outcome of psychiatric in-patient treatment. This may be related to the challenging methodological issues of this field of research: the number of potentially therapeutic relationships that take place in in-patient treatment, the lack of a clear definition and of a well-defined measure.

Method

The authors conducted a literature review on the state of research from 1985 to 2006. They focused on studies in an in-patient or day-hospital to shed light on the influence of the numerous potentially therapeutic relationships that emerge in this kind of treatment.

Results

The first thing to note is the specificity of the relational network in the in-patient setting, which means that conclusions drawn from psychotherapy research cannot simply be transposed to that particular setting. The important aspects that should be taken into account are: the numerous relationships and therapeutic activities, the beginning, pace and duration of treatment or the choice of therapist which are not up to the patient to decide, the severity of symptoms, the short-term goals of stabilization or acute changes. The bulk of published work, however, shows a positive association between the quality of the therapeutic relationship with the main therapist and the outcome of treatment (the authors estimated a moderate size of effect of 0.39 for outcome variables such as improvement of global functioning, symptoms and quality of life), but these studies are methodologically too heterogeneous. The quality of the relationship also appears to influence other aspects of outcome, such as psycho- or pharmacotherapy compliance. The complex relationship network in the hospital, where the patient is involved with members of the whole treatment team and/or other patients, is unfortunately rarely studied in itself.

Discussion

Few studies explicitly analyze this important topic, yet the interactions within the hospital are often the most salient relational experiences and/or models the patient has. The main limits of the studies reviewed here are linked to theoretical issues (lack of a clear definition of therapeutic relationship(s) in psychiatry) and methodological issues (lack of a shared standardized measure). Despite these limitations, the evidence of the impact of the therapeutic relationships in psychiatric hospitals has major clinical implications. These naturalistic studies show that even severely disturbed in-patients are able to receive and benefit from these interactions. This suggests that patients’ experiences, expectancies, motivations, as well as the treatment methods and goals should be discussed in the early phase of treatment. Future research will have to work out a definition of the various therapeutic relationships in the in-patient setting (defining its components and actors), choose or refine measures that take into account the multi-disciplinarity of that setting, and also consider process-oriented research.     

Alliance thérapeutique et engagement : une réflexion sur l’éthique de la prise en charge des patients suicidants en psychothérapie psychanalytique

The ethical questions involved in the treatment of patients who have attempted suicide will be addressed here on the basis of two contradictory positions, which appear in codes of deontology. On one hand, we find individual freedom and protection of the person; on the other, professional secret and shared secret. The reflection, developed along the lines of psychoanalytical theory, is enriched by contributions from crisis management. It is illustrated by means of clinical situations taken from clinical practice in the domain of suicide prevention. What is revealed is the fact that suicide does not correspond, in the case of our patients, to the exercise of freedom and as a consequence, it requires us to intervene. Suicide attempts are often associated with pathologies in which we can find a life history marked by separations, abandonments and trauma, corresponding to a failure of the environment which the treatment must be careful not to reproduce. This implies that, between the contradictory terms evoked above, we make the choice of protection of the person and of shared secret. As concerns the analytically based psychotherapeutic framework, the guidelines of traditional neutrality for the analyst, whose value remains complete, must be redefined toward a more interventionist counter-transferential position.     

Accueil familial thérapeutique et réhabilitation psychosociale. Mise en œuvre de techniques de remédiation cognitive dans un établissement spécialisé

Foster Home Care is in France, since 1989, defined as a specific modality of full time hospitalization. Foster Home Care services offer treatment for individuals suffering from mental illness but can benefit from care in a stable family environment, with an objective of restoring their relational capacities and their autonomy. Foster Home Care thus appears as specific rehabilitation service aiming at the development of autonomy in individuals with severe mental illness. It relies on an interaction between three partners: a patient, a caregiver and a mental health team. It has suffered criticism because it could appear as a simple installation in a chronic process, with little possibility for progress. It is now revisited with a more dynamic approach. Ainay-le-Château hospital, an institution with a long experience in Foster Home Care, has redefined its treatment programme, using rehabilitation techniques. Cognitive remediation is one of them, with therapeutic education and social skills training, aiming at acquiring strategies to reduce functional handicap related to cognitive deficits, thus helping to progress towards recovery.     

Accueil familial thérapeutique. Historique et évolutions récentes

The aim of foster care is to treat patients in a stable environment provided by foster home caregivers paid by a hospital. This mode of treatment has its distant origin in the legend of Saint Dymphna, Irish princess. This princess, exposed to the incestuous ardours of her father the king, decided to flee with her confessor, Gerebene. They landed in Flanders Geel, where she was eventually found by her father and beheaded in the public square. At the same moment an insane recovered his health. Since then, Geel became a pilgrimage for the mentally ill, who stayed there in a family for a fee. In France, the first mental health Act dates back to June 30, 1938. It required that each “department” or district has a psychiatric hospital. At the end of the xixth century, these institutions were overcrowded with chronic patients, incapable of returning to normal life. The psychiatrist August Marie created institutions then called “Family colony” to accommodate these patients. These institutions located in the Centre of France, treated as many as 1345 patients (Dun-sur-Auron) and 1145 patients (Ainay-le-Château). A new act codified this practice in 1989, defining a recruitment procedure for caregivers, specifying the facilities they should offer and the continuity of care they had to insure. Various mental hospitals then created Foster Care units. The hospitals ensuring foster care have to comply to quality controls by the High Health Authority. They offer hospitalization units for the treatment of acute psychiatric of medical episodes. Foster care thus includes these partners: a patient, a caregiver, a mental health and medical team. According to a report in 2011, 3800 patients were treated by foster care that year. The cost is estimated at the rate of 240 € per day, much lower than traditional hospital treatment, but with a better quality of life for beneficiaries.     

Évaluation des besoins des patients et éducation thérapeutique

Therapeutic education aims at helping patients acquire of maintain competencies they need to cope with chronic illness. It goes further than simple information because its objective is to improve autonomy and quality of life, not just treatment observance. Therapeutic education is an important instrument for psychiatric rehabilitation, notably in foster home care. Because of the various possible themes of therapeutic education, our institution worked toward the identification of situation needing a structured program of therapeutic education. A pluridisciplinary group was set up, aiming at building structured therapeutic education programs and following their implementation. This group built a questionnaire for mental health team members, care givers and patients. Mental health team members expressed their views during a focus group. They identified several issues such as: food and overweight, digestive problems, medication side effects, smoking, diabetes. The questionnaire was sent by post to foster caregivers: 63% of them answered. Sixty-four percent of the answers identify one or several problems encountered by patients: lack of information concerning treatment (27%), stress due to vexation (26%), medication side effects (18%), lack of information concerning mental illness (9%). Twenty-four patients were interviewed, expressing their difficulties: over sedation, loneliness and boredom, anxiety, food, information concerning medication and mental illness. Patients expressed specific needs: Food and overweight, information on medication and illness, activities, smoking cessation. This questionnaire, requiring approximately 45 minutes interview, was living positively by patients. This preliminary inquiry led to identification of difficult themes for therapeutic education: medication and illness, smoking, nutritional balance. In order to both identify unmet needs, we decided to use an instrument developed in Lausanne, called ELADEB (Lausanne instrument to evaluate patients’ needs and difficulties)     

Sport et alliance thérapeutique en milieu carcéral

In this report, the author advances the hypothesis that sport activities could compromise a therapeutic alliance in the case of psychiatric follow-ups. The approach is a phenomenological, clinical and anthropological one based on three clinical situations. This hypothesis was verified but has not been applicable to the whole population of prisoners. If psychiatric and psychotherapic follow-ups can not be positively correlated with the notion of therapeutic alliance, there is a risk factor and therefore a predictability of relapse for bipolar disorders and for clinical decompensation whether auto- or heteroaggressive. Finally, the components of the universe of the exercise grounds and of psychopathology in the prison society of the Fleury-Mérogis prison are psychiatry, sports, stimulating and sedative substances. The hypothesis was confirmed by facts, as follow-ups are not frequent due to « too much sport », and to patients « sinking » into a psychopathological process. The following other variables were analysed: sex, age, personal health antecedents and justice antecedents. The three patients studied had a criminal past consisting of sexual assault, murders or drug dealing. Based on available data, the analysis indicates that the three prisoners decompensate along same mode: bipolar disorders followed by immediate admission in a psychiatric hospital, which in turn entails a change in the initial punishment.     

Prise en charge thérapeutique du syndrome de Gilles de la Tourette chez l’enfant et chez l’adulte

Tourette's syndrome is a neuro-psychiatric disorder which starts in childhood and is characterized by the association of motor and vocal tics of which the frequency, type and location vary in time. The numerous ways of neurotransmission of the physiopathology of this illness have been tested. Several psychiatric comorbidities have been described at length among which the attention deficit hyperactivity disorder and obsessional compulsive disorder are the most frequent. The decision to initiate a treatment must take into account numerous factors and notably the repercussions of the pathology on the social and occupational life of the patient which rest on an individual valuation of the illness. Care must first start with psychoeducation allowing a better understanding of the syndrome by the patients and their family. Medicinal therapeutics then intervenes to treat the weak to severe tics affecting the daily life of the patients. The choice of the molecule will differ according to the severity of the illness, to the age of the patient and to the comorbid associations. Psychotherapies such as behavior therapy and supportive therapy are an alternative to pharmacologic treatment. They can be employed alone and may be sufficient for some patients. They can be also associated with classic therapeutics in order to increase therapeutic effectiveness. Finally, deep cerebral stimulation may constitute a new and interesting way, but it is in its developmental stage and needs to be assessed. This treatment is restricted for the time being to cases resistant to the classical treatments and to patients meeting the requirements of eligibility for such treatment.     

L’Ayahuasca : clinique, neurobiologie et ambiguïté thérapeutique

Ayahuasca is a traditional Inca hallucigenic plant. Intoxication by Ayahuasca is an introspective dysleptic experience with a high emotional tonality, particularly well memorised. It can be complicated by physical discomfort, terror reactions, and fits of delirium. The leaves of Ayahuasca contain dimethyltryptamine (DMT), and the creepers contain β-carbolin alkaloids (THH). DMT is a serotoninergic agonist, close to LSD. The β-carbolins inhihibit type A monoamine-oxydases that break down DMT in the intestine and allow passage through the intestinal wall and prolong its actions. The β-carbolins give Ayahuasca its purgative and emetic effects. There have been a number of debates on the use of Ayahuasca as a therapy. The promoters suggest its use for the treatment of certain addictive pathologies. It will allow a highly emotionally charged access to the unconscious in spiritualistic contexts with groups that have a chamanistic resonance. This approach is challenged by scientific spheres which point out the methodological weakness of these studies and the absence of detachment regarding the subjects’ relapses and suggestibility. The authors bring to the fore the risks of distortions of affective perception, the over-investment of personal experience and the primacy of subjectivism, and the weakening of the system of reality. This gives rise to ways of thinking that are paralogical, interpretative, intuitive and highly inspired by passion. This, in turn, attracts the most vulnerable and suggestible subjects, entrains a rigidness of psychic processes and an impoverishment and a narrowing of emotional life around the object that is Ayahuasca. Health authorities have classified Ayahuasca as a dangerous substance on the same grounds as other psychodysleptics.