Accompagner les professionnels de santé dans la révélation de l’erreur : de la révélation à soi à la révélation à l’autre

Error disclosure is now an ethical and professional obligation for health professionals and seeks to improve quality and safety in healthcare. Literature has highlighted the numerous benefits of error disclosure and several authors have described the options for handling this situation. However, it is not quite that simple to be honest and open and follow a protocol that instructs professionals to explain, support and apologise in situations where they are subject to criticism. While the many personal, institutional and social factors that hinder open disclosure have been identified, little attention has been paid to the obstacles associated with the psychological impact of disclosure, thereby limiting the debate on how professionals might be supported in their efforts to cope with error disclosure. The psychological impact of error on professionals is a well-established fact. Physicians are “second victims” likely to be emotionally affected by medical error. Emotional distress, anger, isolation, fear, guilt and shame can be intense, suggesting that, far from being an isolated act in professional practice, a medical error is a life event that modifies the psychological balance of a professional. Studies in the humanities have shown how work shapes individuals’ identities. The choice to heal and care for is indicative of the ideals related to professionals’ life histories, cultures, family models and representations of health and disease. Work and, more specifically, recognition at work from their peers, patients and relatives enables health professionals to support their ideals and establish a coherent identity, and to belong to a workgroup. The error foreshadows a rupture which plunges the professional and the team in a state of vulnerability that rules out the professional's or the team's possibility to be part of a process of disclosing the error. In these conditions, a policy of security of care also involves a guarantee of the caregiver's and the team's psychological security. The term psychological security was developed by the psychoanalysis who emphasised the individual's need to evolve in a “sufficiently good” protective environment that allows him/her to contain his/her emotions, while giving the individual the possibility to express and discuss them. This space implies a relation of trust between individuals. Trust refers to the idea that the individual can trust someone, it is based on the capacity to create relations. It is only through trust that the professional will be able to open him/herself to others and construct a space where the errors and the doubts that he/she has in the context of work are shared. But if trust is essential, it is also dangerous because it implies accepting the risk of being dependent on those considered as trustworthy and the risk that they will not live up to the professional's expectations. As a consequence, the professional will only have trust when he/she has evaluated the possibility of cooperation and more precisely, as stated by Hardin, a cooperation in which the professional's interests are “encapsulated interests”, in other words the interests of others. Therefore, this cooperation depends on each member of the team seeing his/her interests as being partially those of the others. Cooperation within a service reveals the relations of trust between the professionals and shows the relations of dependence that each one maintains with the others for the good administration of care. Thus the creation of relations of cooperation between the team members proves to be an important indicator to determine the professional's possibility to adhere to a process of disclosing the error. This approach shows that professionals must address multiple rather than single disclosures: to the self, and to others (colleagues, hierarchy, patients and families) who will mobilise specific knowledge, emotions and psychological defences. To avoid cases where disclosure takes on dimensions as tragic as the actual errors committed, it is important to pay attention to the psychic state of healthcare professionals by offering a space of free expression that enables them to better understand their feelings and gain a sense of support in order to restore their ideals and professional identities. Finally, it's important to emphasize that disclosure also depends on the preservation or restoration of the relations of cooperation within the team. Disclosure cannot be prescribed, it must emerge within a workgroup who allows the error to be thought over, communicated and shared. In this context, disclosure becomes a group rule that is known to all. A health professional who feels sufficiently supported might, in turn, support a patient and/or his/her relatives and engage in meaningful disclosure.     

L’enfant autiste et son parent face à l’échec de l’intersubjectivité : une clinique de la narrativité

Aim

This article examines the failure of the processes enabling access to intersubjectivity and to primary subjectivation in the treatment of small children presenting autism, and the consequences thereof in the development of parenting exercised by the mothers and fathers of such children. The psychotherapeutic processes implemented via narrative and testimonial functions during consultations appear necessary to relaunch narrative identity and the capacity for parental reverie.

Effets de la maltraitance sur la régulation émotionnelle des enfants et des adolescents confiés à l’Aide Sociale à l’Enfance

ObjectivesThis research aims to compare coping strategies (strategies developed to cope with stress) and temperamental dimensions used by children and adolescents have not been maltreated and those who have been. The aim of these analyzes is to identify the effects of age as well as vulnerabilities and resources for children and adolescents who have been maltreated.Materials and methodsA total of 232 children and adolescents aged 7 to 16 years participated in this study including 115 who have never been maltreated (control group) and 117 have been maltreated and are living in foster care (placed group). Each young people responded to a scale measuring the frequency of coping strategies (Kidcope) as well as a questionnaire of temperament (questionnaire d’auto- et d’hétéro-évaluation du tempérament en sept facteurs pour l’enfant d’âge scolaire et l’adolescent).ResultsAn analysis of variance (ANOVA) was performed for each coping strategy and temperamental dimension to evaluate the consequence of maltreatment on the emotional regulation, according to the slice of age. The age-based comparison of control and placed groups reveals major differences in the use of certain coping strategies as well as in the temperamental dimensions of maltreated children and adolescents. This confirms that the child's life experience influences his way of understanding his environment and affects his individual resources.ConclusionsThe results show vulnerabilities of emotional regulation for children and adolescents who have been maltreated. These aspects underline the importance to think about supports in order to promote the development of some coping strategies and to reduce the stressors. These points will be discussed with preventive and therapeutic used to improve coping skills and emotional regulation.     

La faible estime de soi est corrélée à l’intentionnalité suicidaire,indépendamment de la sévérité de la dépression

Introduction

Suicide is a major Public Health concern, and low self-esteem might represent a major risk factor. Our main objective was to assess the correlation between self-esteem and suicide intent. More specifically, we aimed to examine the relationship between the different dimensions of self-esteem (total, general, familial, professional and social) and suicide intent. We also sought the role of depression in the relationship of self-esteem to suicide intent.

À propos de l’expérience de la torture

The large influx of asylum seekers confronts public mental health services with the suffering resulting from extreme political violence. Among these patients, survivors of torture present a unique clinical profile of which clinicians should be made aware. While certain researchers have proposed useful concepts, the statements of witnesses and the writings of clinicians constitute the point of articulation between theory and practice. In this article, we will attempt to understand the ways in which torture results in psychosis (“a laboratory of psychosis”), notably through the specific and ambiguous role of the imaginary. A specific focus will be dedicated to the processes of humiliation, which illuminate a dialectic between the body and the mind, between the physical wounds and the long-lasting injuries inflicted on the soul; torture causing, intentionally, the possibility of a rupture between the ego and the ideal of the self. Finally, the article will critically examine the role of the therapist; so that clinicians will be able find a favorable resolution to the pathogenic conflicts involved.     

Lecture des troubles de personnalité limite à travers la théorie de l’attachement

Borderline personality disorders concern clinicians and caregivers because of the violent and impulsive nature of their behavioral and affective reactions, which often confronts them to a feeling of helplessness and incomprehension. Indeed, it may be difficult to deal with self-harm, massive anxiety, intense affects and interpersonal ruptures, which are often present in the life course of the borderline patients. Their distress is particularly difficult to accept as it takes place in the therapeutic link, which reveals the core of the patient's attachment problematic. This paper aims to draw up an overview of borderline personality disorders, in light of attachment theory, which could help to clarify the involved mechanisms and gather the described behaviors in a coherent unit. Many studies relating to borderline personality disorder and attachment theory highlight what constitutes the specificity of these disorders through an integrative approach. Thus, the combination of an insecure attachment style, biological vulnerabilities and environmental stressors like traumatisms may induce the establishment of many defensive mechanisms, such as attachment system hyperactivation, emotional dysregulation or mentalization's failure. People suffering of borderline personality disorder activate these mechanisms as soon as they have to deal with real or imagined abandonments related to one of their attachment figures. However, in view of the massive anxiety and the severe disruption, those inefficient mechanisms cannot enable a good resolution of stressful situations. Consequently, borderline patients are likely to resort to new kind of emotional regulation such as suicidal, destructive and impulsive behaviors. Attachment based theories focus on these defensive mechanisms and inadequate attempts of emotional regulation, in order to propose an appropriate treatment for borderline personality disorder.     

De l’aménagement de la relation à la mobilisation thérapeutique des auteurs de violence sexuelle – À propos de l’Entretien Clinique de Lausanne

The therapist may have reactions of shock, rejection, fascination or defense when meeting with patients who are sex offenders, a response that is intuitively provoked by the patient's incarceration or the duty of care. Based on this observation, and on the clinical assessment questionnaires that are specifically developed for this population, this article presents the process of development and the theoretical foundations that were the basis for a new version of a clinical interview destined for sex offenders. This new framework for the clinical interview was created in relation to the three main functions of the questionnaire, in particular, for interpersonal mediation, investigation of psychological functioning and to identify therapeutic strategies. Thus, the goal of the Clinical Interview of Lausanne is to be an object for the mediation of the therapeutic relationship that can create a space where the manifestations of counter-transference by the therapist can be reduced, while still sufficiently respecting and containing the patient's subjectivity. In this way not only can the patient's psychological functioning in relation to his/her sexual offenses be assessed but also his/her disconnection and denial can be gradually resolved. Based on classic and recent psychoanalytical literature and the clinical experience with patients in the Service de Médecine et de Psychiatrie Pénitentiaires (SMPP) of the Centre Hospitalier Universitaire Vaudois (Switzerland), we present the hypotheses used to develop this new interview framework. This new version is in the process of being evaluated in a university research study to validate the theoretical elements presented in this article.     

Les organes endommagés dans la constitution de l’image de l’esprit

Objective

This article sets out to clarify the relationship between the organic pathologies and the images of the corresponding organs. In this type of construction, it is as if the mind were confronted with an internally generated form of pareidolia. As in maladjustment, manifestations of pareidolia undergo change when the organ is damaged; it is thought that the subject has a distortion in the production of images. In this work, we compared two very different diseases: a skin disease (psoriasis) and a heart disease (coronary heart disease). Here is the hypothesis we propose.

Troubles de l’humeur et chirurgie de l’épilepsie : une revue de la littérature

AimsHistorically, there is a strong link between depression and epilepsy. Patients with epilepsy are four to five times more likely to develop a depressive syndrome. It seems that the link between epilepsy and depression is bidirectional. There is little data on mood disorders secondary to epilepsy surgery. The goal of epilepsy surgery is to reduce the number and frequency of attacks, which in turn would allow improvements in mood disorders and cognitive impairment.MethodsA systematic search of the international literature was performed using the bibliographic search engines PubMed and Embase. The following MESH terms were used: epilepsy surgery AND (depression OR depressive disorder OR mood disorder). We also used the “related articles” of PubMed, bibliography surveys, conference abstracts and Google Scholar to identify additional relevant papers.ResultsOf the 130 studies found by the systematic search, 112 are excluded because they did not take into account the mood disorders secondary to epilepsy surgery. Fifteen studies are included in this review of the literature with a case study. Depression is the psychopathological condition that is the most frequently studied. According to several studies, the prevalence of depression is approximately 30% with nearly 70% of cases diagnosed during the first three months following epilepsy surgery. The majority of patients presented depressive symptoms during the first 3 to 12 months after epilepsy surgery. In these studies, the risk of developing depression is correlated with the existence of previous depressive elements relative to the epilepsy surgery. A small number of studies reported cases of de novo depression. Studies have shown a correlation between very good to excellent control of epileptic seizures and a persistent improvement of mood disorders. It would seem that depressive symptoms post-surgery are more common when the surgical intervention concerns the temporal lobe and in particular mesial resections. There are only very few cases of maniac episodes. Hamid et al. showed an increased risk of suicide waning after the epilepsy surgery over a period of 5 years.ConclusionMood disorders are common psychiatric comorbidities in epilepsy surgery. The detection, prevention, and treatment of these symptoms in patients eligible for epilepsy surgery pose major challenges for psychiatrists and neurologists, requiring their close collaboration.     

Fonctions de l’anticipation et images de l’homme : apports de la philosophie analytique à la psychiatrie du futur

This study combines the conceptual analysis method and the psychopathological and psychiatric clinical method to elucidate the functions of anticipation. The meaning of the term anticipation has evolved over time according to philosophical currents. It is at the turning point of the 19th and 20th centuries that the emphasis will be placed on anticipation as a process of thought, an operation of the mind, generating an action of representation of concepts, theories or conduct, of future acts directed towards an object to be built. Anticipation is both an act of thought and a conduct; it is not a static process and the functions of anticipation are not analyzed on the basis of the same criteria according to whether the individual is evoked or referred to as the collective, whether we focus on the real or the virtual, whether we explore the world of life or the physical world. The author analyses here the peculiarities of anticipatory thinking in the psychopathological and psychiatric clinic as well as the impact of the entanglement between manifest and scientific images described by Wilfrid Sellars. The author recalls the contribution of Professor Sutter on the inability to anticipate in depressed patients, his own analyses of parental anticipation, the child's ability to anticipate and failures in mental disorders. It appears in these settings a primacy of the manifest image of man in relations to others and a primacy of the scientific image of man in the theoretical constructions that we operate with the objective of a creative anticipation. The manifest image of man then appears as one of the referents of thought that restrains or, on the contrary, energizes any anticipatory process insofar as elements of the scientific image also infiltrate it. In all fields, anticipation intersects various aspects, analysed with reference to the language used, common or specialized. The result is the creation of anticipatory systems representing all sectors of knowledge and the need to use the analytical method. To anticipate in the context of mental health is, at the same time, to rely on the manifest image of the man of our time and to project the scientific image of the man in a future time, of which we do not yet conceive the technical, ideological and societal limits. It is also to wonder what new objects of thought will be on a distant horizon.     

De la connaissance à la croyance ou l’égarement de Jules Luys,un cheminement intellectuel toujours d’actualité

A contemporary of Jean-Martin Charcot, Jules Bernard Luys was a neurologist and psychiatrist who remains known for having described the corpus Luysii, a grey subthalmic formation which became the subthalmic nucleus. His work as an anatomist is preserved in two innovative books, the first designed to give a three-dimensional view of the nervous system in 1865, and the second ushering in anatomical illustration using photography and introducing micro-photography in 1873. Splitting his time between La Salpêtrière Hospital and the Ivry asylum, Luys presented brain physiology in his book Le cerveau et ses fonctions (the brain and its functions) to shine light on its disorders, as an introduction to his voluminous Traité clinique et pratique des maladies mentales (clinical and practical treatise on mental illnesses), which already showed the work of a fertile imagination attempting to connect mental illnesses with anatomical observations expressly interpreted. His 1886 appointment at La Charité Hospital provided him with an opportunity to imitate Charcot's Lessons, so he immersed himself in the study of hysteria. With the help of a fervent believer in occultism, Gérard Encausse, who, unbeknownst to him, manipulated the young women he ran his experiments on, Luys made the most extravagant observations, believing naively in his findings and proceeding without critical analysis. This story of a great scientist, slipping into irrational thinking by abandoning the benefits of doubt, is an opportunity to explore the mechanisms leading to this deviation, which is not without parallels with more recent deviations during the AIDS and Covid-19 pandemics.     

Prévention de la récidive suicidaire à l’adolescence par SMS ou autre media

Preventing suicidal recurrence in adolescence is one of our concerns when we receive a young patient in the aftermath of a suicide attempt. Indeed, suicidal recurrence remains significant, between 14 % and 28 % in the year following the suicide attempt studied. For the purpose, the French recommendations advocate a sufficiently long follow-up and value the maintenance of the link with the care service, which is sometimes difficult with adolescents who often have no demand for care. This paper presents three studies of suicidal adolescents, which have in common a convergence towards an idea: the interest to set up a monitoring system in postvention.

Formations de l’idéal,Hikikomori et virtuel à l’adolescence

Goals

Withdrawal behaviours among teenagers have become a major topic in both clinical practice and the specialized literature. Known since the 1980s in Japan as Hikikomori, these behaviours are found across international nosographies in a variety of models. They are not always accompanied by intensive video gaming. There are varied uses of digital technology among teenagers, in terms of both quantity and quality. They can relate to the formation of an ideal, on the boundaries between virtual reality and illusion, it can also be a step toward the renewal of social relationship, since it enables a less threatening confrontation with the object.