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La diversité des approches théoriques et des techniques en psychothérapie est une richesse, mais elle peut parfois entraver l'élaboration d'une réflexion commune sur les psychothérapies et leur efficacité. L'objectif de cet article est de montrer que la notion d'alliance thérapeutique permet une compréhension intégrative du processus de soin psychique. Nous proposons une revue narrative sur l'alliance thérapeutique incluant la diversité des théories et des pratiques thérapeutiques. Nous prenons appui sur le modèle contextuel de Wampold (2001) et le modèle d'alliance thérapeutique proposé par Bordin en 1979. Les études que nous présentons portent principalement sur des psychothérapies individuelles auprès d'adultes, et sont majoritairement issues de la littérature internationale des cinquante dernières années. Nous explorons les implications épistémologiques et pratiques de ces études. Un pan de la recherche explore les liens entre alliance et résultats thérapeutiques, tandis qu'un autre explore l'alliance comme processus thérapeutique en soi. L'approche contextuelle et le modèle d'alliance permettent de proposer une définition de la psychothérapie qui est commune aux différents courants de pratique et offrent un cadre pour prodiguer des soins psychiques de qualité. Psychotherapy is an immensely diverse field of practice, in which multiple models and protocols coexist. This diversity can be an asset but can sometimes hinder the path toward a common understanding of what works in psychotherapy. The aim of this article is to show that the therapeutic alliance construct can provide an integrative frame of reference when it comes to understanding the psychotherapeutic process. This narrative review of the therapeutic alliance concept embraces the diversity of theories and practices in psychotherapy. We draw on the contextual model (Wampold, 2001) and the therapeutic alliance model (Bordin, 1979). The reviewed studies mainly focus on individual psychotherapy for adult patients and are drawn from the international literature over the past fifty years. We explore the epistemological and practical implications of these studies. One part of the research explores the links between alliance and psychotherapy outcomes, while another explores alliance as a therapeutic process. The contextual approach and the alliance model can be used to provide a definition of psychotherapy that is common to different schools of thought. These concepts offer a framework for quality psychological care. [ABSTRACT FROM AUTHOR]

Les exilés ont souvent vécu de multiples traumatismes et lorsqu'ils arrivent en France, ils restent en général dans une situation sociale précaire avec un certain nomadisme et un isolement important. L'offre de soins existante pour la santé mentale du public exilé n'est malheureusement pas suffisante actuellement ; aussi, multiplier les moyens et innover dans les prises en charge permettrait de soulager la pression de la demande. La présentation de l'État de Stress Post-Traumatique (ESPT) chez ce public est très fréquemment somatique, avec une errance diagnostique initiale fréquente. À travers trois vignettes cliniques, nous pouvons observer que le médecin généraliste formé, en tant que médecin de premier recours, peut déjà rétablir un lien de confiance qui est souvent rompu, redonner un certain sentiment de sécurité et apporter du soutien, ce qui est la base du soin dans le psychotrauma chez ces patients souvent déshumanisés, isolés et loin de leur environnement soutenant culturel. Il est possible pour le médecin de dépister, orienter, et prendre en charge selon ses compétences ces psychotraumatismes en étant une personne ressource et en utilisant une méthode complémentariste, tout en prenant en compte l'ensemble des symptômes présentés par les patients. Prendre en charge l'ESPT en situation transculturelle nécessite un décentrage indispensable et une prise en charge globale du patient, afin d'obtenir une alliance thérapeutique nécessaire à la qualité des soins. Or le travail en médecine générale est déjà dans cette démarche de raisonnement. Enfin, la continuité des soins dans la durée permet d'éviter les ruptures de soins qui peuvent alors être traumatogènes pour ces patients. Le travail du médecin généraliste permettra alors d'améliorer l'accès aux soins psychiques des exilés et développer des structures spécialisées dans le psychotrauma des personnes migrantes, tout en innovant dans la prise en charge. Exiles have often experienced multiple traumas, and when they arrive in France, they generally find themselves in precarious social situations, often with a certain level of nomadism and significant isolation. Unfortunately, the existing mental health care services available for exiles are currently inadequate, and more resources and innovative approaches to providing care would help alleviate the pressure of demand. The presentation of Post-Traumatic Stress Disorder (PTSD) in this population is often somatic, with frequent initial misdiagnoses. Through the study of three clinical vignettes, we are able to substantiate that a trained general practitioner, as the primary care physician, can readily establish a bond of trust that has often been broken, restore a sense of security, and provide support, which is at the core of trauma care for these patients who are often dehumanized and isolated, far from their supportive cultural environment. The general practitioner can screen, refer, and manage these psycho-traumas according to their competence, serving as a resource person and using a complementary approach while taking into account all the symptoms presented by the patients. Addressing PTSD in a transcultural context requires essential decentralization and comprehensive patient care to establish a therapeutic alliance necessary for quality care. This approach is increasingly being used in general medical practice. Additionally, the continuity of care over time helps prevent breaks in treatment, which can be traumatic for these patients. The treatment provided by the general practitioner will help to improve access to mental healthcare for refugees and to develop structures specialized in treating psychotrauma in migrant populations, while at the same time being innovative in patient care. [ABSTRACT FROM AUTHOR]

The practices of psychologists and teachers present similarities and differences, with a common commitment to promote individuals’ progress. The interactions between the patient and their psychologist, as well as between the learner or class group and their teacher, imply a relationship likely to promote-or not-the objectives of the care or the learning. How do the professions of psychologists and teachers approach the singularity of the user and the group? What training is offered for this purpose and what work does this involve on the part of these professionals? How can we consider the therapeutic alliance and the quality of the educational relationship as supports for the commitment of the psychologist and the teacher or trainer in a scientific and professional research process allowing the relationship to be thought about? [ABSTRACT FROM AUTHOR]

The complex work of addressing intergenerational adversities, like violence, abuse, and neglect through perinatal psychotherapy, is understudied. Especially noticeable is the paucity of studies giving voice to the therapists. This study explored therapeutic processes through the perspectives of seven Norwegian therapists. A qualitative approach was chosen with individual interviews and a follow‐up focus group. Data were analyzed using reflexive thematic analysis. We identified one overarching theme: To maintain a reflective therapeutic capacity, and two main themes with associated subthemes: 1) Alliance work when a caring system comes to therapy to fight generations of adversities and 2) The complex therapeutic work of addressing generational adversities in perinatal psychotherapy. Findings from the present study indicate that maintaining a reflective stance is essential yet challenging when addressing intergenerational adversities, requiring a holding environment for the therapists. The primary vehicle of change was perceived as a safe enough therapeutic alliance to explore new ways of being together, contrasting earlier experiences. A key question raised was how to give caregivers enough time to trust the therapist without compromising the safety and development of the child. The essence of the therapeutic work was to reduce risk factors and increase protective factors through multiple ports of entry. [ABSTRACT FROM AUTHOR]

Changing behavior to improve health has become a public health issue. Motivational interviewing (MI) is a scientifically proven relational approach derived from Rogerian psychology. Its aim is to increase patients' motivation to undertake a change that will benefit their health. MI has proven its effectiveness in a wide range of fields, including addiction, chronic illness, prison, education, and sports performance. Its practice requires an expertise that is itself initiated by specific training. MI has many similarities with therapeutic patient education (TPE), not only in its theoretical foundations but also in its practice. Empathy, empowerment, a positive outlook on patients' skills and future, shared hope... belong to both MI and TPE. Thus, MI and TPE are complementary and, when practiced together, can improve the effectiveness of TPE programs, notably by increasing patients' motivation to commit to and remain in these programs. Joint training courses in MI and TPE should be offered to caregivers, to ensure that patients' difficulties are dealt with as effectively as possible. [ABSTRACT FROM AUTHOR]

Attachment theory has found renewed interest among psychotherapy researchers in last decades. There is growing evidence for the role of adult attachment as a predictor of treatment process and outcome. Attachment styles are hypothesized to remain stable over time, however, research also shows that internal models of self and others can be revised through interpersonal experiences that diverge significantly from the primary attachment figure. More recently a new concept has appeared and allows a better understanding of the nature of the bond between the patient and his therapist from attachment theory perspective, it is the concept of patient's attachment of the to the therapist. At first this article reviews the empirical evidence on the link between adult attachment styles, patient's attachment to therapist, therapeutic alliance, and outcome. Secondly, we will present results of an empirical study conducted in Algeria which aimed to examine the links between the patient's attachment to the therapist, the patient's adult attachment styles and the therapeutic alliance, to finally end with a discussion on the interest of the variable of the patient's attachment to the therapist for psychotherapy research and clinical intervention. [ABSTRACT FROM AUTHOR]

Introduction: The development of psychotherapies has been accompanied by assiduous research concerning the evaluation of their effectiveness. Since the major psychotherapeutic models have demonstrated their effectiveness, the focus has shifted to understanding this effectiveness and to identifying factors common to the therapies, such as the therapeutic alliance, which would be predictive of effectiveness (Castonguay, 1993; Norcross & Lambert, 2019; Wampold, 2017). Method: We propose here a review of the literature in order to establish the state of research concerning this new paradigm of common factors that offers an innovative understanding of the therapeutic evolution process. Results and discussion: The therapeutic alliance is defined by the affective bond that develops between the therapist and the patient, as well as the collaboration between the two partners on the definition of the goals and tasks of therapy (Bordin, 1979). This conceptualization of the alliance seems the most relevant, because it positions psychotherapy as a professional act according to a specific methodology (Brennstuhl & Marteau-Chasserieau, 2021). Certain characteristics of the therapist and the patient also have a significant influence on the level of alliance and the outcome of the therapy (Wampold & Brown, 2005). Some therapists are reported to be more effective than their peers and have better outcomes regardless of the therapeutic model used (Baldwin et al., 2007; Wampold, 2001). The common factor paradigm for exploring the processes at work within psycho therapies seems promising and offers a great opportunity for collaboration between clinicians and researchers to understand the effectiveness of psychotherapies. [ABSTRACT FROM AUTHOR]

This article introduces the Change Process Research paradigm. In 1966, Kiesler laid the foundations for this new paradigm by insisting on the interpersonal relationship and the complementarity of the patient's responses to the therapist's interventions. Continuing this work, Greenberg (1986) is interested not only in the singularity of the therapy but also in the singularity of the different episodes of the therapy. By considering the context and asking the participants (therapist and patient) for their point of view, he proposes a method to conduct task analysis for significant events in such a way as to better identify, describe, explain and predict the change processes. We will illustrate this Change Process Research paradigm by studying an episode in family therapy using the patients' perspective to identify the significant event. The method allows to reduce the gap between practice and research because the clinician can rely on this analysis when it is done during the therapy to better adjust to the patients during the following sessions in a self-supervision practice. [ABSTRACT FROM AUTHOR]

Researchers and clinicians live in increasingly separate worlds, precipitating psychotherapy into a crisis of legitimacy. This paper hypothesizes that the therapeutic alliance, as an integrative variable, is an element capable of reducing this gap, considering in particular that the alliance between researcher and clinician is based on the same principles as the working alliance between patient and therapist. A few examples of empirical research allow us to address three conflicting aspects of our current knowledge about the alliance: as a common factor or as a specific agent, as useful to the researcher or useful to the clinician, and finally the distinction between the trait-component and the state-component of the alliance. The time has come to strengthen this vital alliance between research and clinical practice. [ABSTRACT FROM AUTHOR]

Background: Therapeutic alliance represents a rarely studied object when it relates to nurses and care provided by a nursing team in acute care hospitalization.Objective: The objective was to study how factors might influence the therapeutic alliance built between nurses and aides and adult inpatients in an acute care unit of sectorial general psychiatry.Method: This is a prospective, observational and cross-sectional study using a therapeutic alliance measurement scale. Therapeutic alliance (TA) score was measured with a STAR-P scale in a sample of 240 patients.Results: The median score found is 33.4 (±7.8) out of a maximum theoretical score of 48. The global score of TA in patients aged 60 years old or more is significantly higher than the score of patients between 18 and 29 years old (p=0.021). The lack of external follow-up in the three months after hospital release is not associated with TA global score (p=0.73). If inpatients, no matter what their diseases or types of care are, under legal obligation or not, consider their TA is rather good after their hospital stay. Only sociodemographic factors like age, housing conditions (insecure or sustainable), having a job or not, living alone or with a partner affect TA and follow-up.Conclusion: Results evoke concepts of anomie and attachment, that seem to play an important role in the lack of follow-up after hospital stay, and indicate the mandatory global approach to care and an involvement of health professionals as well as social beings, where empathy must find its place. [ABSTRACT FROM AUTHOR]

Le concept d'injustice épistémique s'intéresse à la manière dont la capacité d'un sujet à produire du savoir peut être déniée ou minorée. Nous nous proposons ici d'étudier son intérêt en psychiatrie, de la pratique clinique à la nosographie. Après avoir défini les principales injustices épistémiques, nous étudions leur application à la relation médecin-malade. Nous cherchons enfin à comprendre quel pourrait être l'apport de ce concept dans la clinique psychiatrique mais aussi dans la classification des troubles mentaux. Les patients souffrant de troubles mentaux sont particulièrement vulnérables aux injustices épistémiques. Des facteurs prédisposants peuvent être identifiés, certains communs à tous les troubles psychiatriques, d'autres spécifiques à chaque pathologie. Les classifications en psychiatrie reflètent aussi l'existence d'un déséquilibre épistémique entre usagers et communauté scientifique. L'inclusion des usagers dans l'élaboration de la nosographie est de plus en plus consensuelle, car elle pourrait permettre d'améliorer leur validité, avec un impact sur la pratique clinique, sur les questions de stigmatisation ou encore le financement de la recherche. La notion d'injustice épistémique pourrait constituer un cadre conceptuel pour mettre en évidence les situations dans lesquels le discours du patient n'est pas suffisamment pris en compte alors qu'il constitue un savoir pertinent. Il nous semble donc utile dans une approche intégrative visant à mieux articuler savoirs médical et expérientiel, sous réserve du développement d'outils pour mieux recueillir ce savoir expérientiel. The concept of epistemic injustice was developed in 2007 by Miranda Fricker. It designates a specific category of prejudices, where the subject's capacity to produce knowledge is denied or undermined. Several authors have applied this concept to the field of health and argue that people with a medical condition are more vulnerable to epistemic injustices than healthy people. In psychiatry, some authors believe that patients are even more vulnerable to such injustices in clinical practice than patients of other specialties. Some others identify certain forms of epistemic injustice in the classifications of mental disorders, and postulate that it could lead to epistemic losses in classifications, diagnoses and care. In France, this concept is relatively unexplored in psychiatry. The aim of this paper is to identify and summarize the potential contributions of the concept in psychiatry, from the clinical practices to the definition of mental disorders. First, we will define the main types of epistemic injustice described by Fricker. We will then see how these injustices can occur in the field of health. Finally, we will study why patients with a mental disorder are particularly affected by these injustices, the potential impact on psychiatric nosography and the ways to address these epistemic injustices. There are two types of epistemic injustice. In testimonial injustices, a person's speech is unwittingly considered to be of little or no credibility by his interlocutor, because of negative prejudices against him or his community. Hermeneutic injustice occurs when a person fails to convey their experience, due to a lack of hermeneutical resources to interpret and communicate it. In healthcare, the credibility of the patient's testimony can be diminished by several factors and general prejudices. Additionally, there is a lack of interpretive resources to understand and share many aspects of the experience of illness. In addition to this, the epistemic privilege accorded to healthcare professionals, particularly physicians, leads to accentuating the epistemic imbalance. The type of doctor-patient relationship, and its evolution, also impact the respective epistemic positions. In psychiatry, patients are seen as more vulnerable to epistemic injustices. Crichton thus identifies three common factors to all mental disorders, including a general prejudice of irrationality and unreliability. In addition, each pathology has specific factors exposing patients to a weakening of their epistemic capacity. To correct these injustices, several tools have been proposed, such as including the study of epistemic injustice in physician's training or using a phenomenological toolbox. Anke Bueter also suggested the existence of a specific form of testimonial injustice in psychiatric classifications, known as "pre-emptive", which excludes the possibility for ill people and their relatives to testify. However, taking these testimonies into account could act as a corrective mean in the construction of nosography. This nosography is indeed based, in psychiatry, on value judgments, due to the lack of objective data. Several authors, including Bueter, therefore call for a better integration of users in the revisions of classifications, to improve their validity. This could have implications for the clinic, research and its funding, and other issues such as stigmatization. However, how exactly the users' point of view could be integrated still needs to be defined. Several proposals have been found in the literature. We consider that the concept of epistemic injustice is a useful tool towards a better articulation between experiential and medical knowledges. In clinical practice, if the clinician is trained in this concept, he will be able to identify situations at risk of epistemic injustice, attempt to neutralize this imbalance and thus carry out a more exhaustive clinical examination and more appropriate care for the patient. Regarding nosography, strengthening the epistemic position of users and integrating their knowledge could improve the validity of classifications. The question of the validity of psychiatric nosography is a problem that the scientific community has faced for a long time, and it therefore seems interesting to continue this reflection through the concept of Fricker. In both cases, it is necessary to continue developing tools to better define, analyze and integrate this experiential knowledge. [ABSTRACT FROM AUTHOR]

In this article, we present two psychotherapeutic interventions aimed at helping the patient to regulate certain self-defeating behaviors. We use them occasionally and on a part-time basis with patients older than 15-16 years, including them in larger and more traditional therapies where attentive listening plays a major role. The first intervention is to encourage the patient to overtly fight, with appropriate exercises, self-defeating symptoms such as anxious ruminations. The second is to subtly challenge the patient to acknowledge the absurdity of his symptoms, for example through judicious use of humor. Both aim to put the patient back in the position of actor, by making him aware of his potential to regulate these counter-productive ways of thinking and behaviors, by triggering a reaction of healthy rebellion against them and by reactivating his creativity. The indications are discussed according to various parameters specific to the patient and clinical diagnosis. [ABSTRACT FROM AUTHOR]

Aditi, 18 years old, is hospitalized in psychiatry for eating disorders. We met her in the context of psychomotor therapy. This care, correlated with psychological, psychiatric, nursing and dietetic follow-ups, allowed this young woman to externalize her emotions and to accept a less anxious future. This article traces some of the steps of regression that were useful to Aditi in allowing herself to accept behaviors that she considered shameful. She accepts her majority and her role as a woman in a singular way, far from the paralyzing societal injunctions. The co-created therapeutic alliance is part of the transferential psychiatry where care is not only technicality but where it is elaborated around a joint adaptation and an understanding of non verbalized needs. [ABSTRACT FROM AUTHOR]

Dans le monde, les technologies sont de plus en plus utilisées en psychothérapies, et plus largement dans le domaine de la santé mentale. Parmi ces technologies, les jeux vidéo et les robots ont donnée lieu à un grand nombre de recherches. Pour autant, ces études ne décrivent pas précisément : d'une part, les modalités d'utilisation de ces technologies dans les dispositifs en psychothérapie ; d'autre part, quel niveau de fonctionnement en psychothérapie (explicite ou implicite) est concerné par ces dispositifs. Cette recherche poursuit donc l'objectif de présenter les principales orientations thérapeutiques de ces dispositifs, tout en les croisant aux niveaux de fonctionnement en psychothérapie. Pour conduire cette revue, nous avons utilisé une perspective qualitative et conceptuelle, en suivant trois étapes clés (définition du périmètre de l'étude, recherche documentaire et analyse de la littérature), et consistant en une intégration des publications organisées d'une manière thématique, et regroupées ensuite par orientation en psychothérapie. D'une part, trois orientations thérapeutiques sont distinguées : l'utilisation des technologies comme des objets thérapeutiques en eux-mêmes (à la manière des serious game) ; l'utilisation de ces technologies pour faciliter l'adhésion, l'alliance et la communication thérapeutiques (« médiation relationnelle » soignant-patient ou psychothérapeute-patient) ; l'utilisation des jeux vidéo et des robots comme des cyber-médiations en psychothérapie (« médiation thérapeutique » psychothérapeute-patient). D'autre part, ces trois orientations ne semblent pas occuper le même espace au sein des deux niveaux de fonctionnement en psychothérapie. La différence entre la première et la troisième orientation semble tenir en la présence systématique ou non du psychothérapeute. Les limites de cette recherche sont nombreuses, la démarche étant essentiellement qualitative et conceptuelle. Des études complémentaires devront être entreprises. Par ailleurs, les limites potentielles de ces utilisations sont soulignées : les études contrôlées et randomisées sont rares, et les publications sans données expérimentales sont parmi les plus courantes. De plus, les données longitudinales font défaut, notamment en ce qui concerne le maintien et la généralisation des résultats dans le temps. Technologies are used increasingly today in psychotherapy and especially in the field of mental health. Among these technologies, video games and robots have given rise to a large amount of research. However, these studies don't describe precisely the modalities of use of these technologies in psychotherapeutic settings, or which, level of functioning in psychotherapy (explicit or implicit) is concerned by these devices. The aim of this research is to highlight the main therapeutic orientations of the devices while crossing them at the levels of functioning in psychotherapy. To conduct this review we used a qualitative and conceptual perspective and followed three key steps (definition of the perimeter of the study, documentary research and analysis of the literature). The literature has been organized in a thematic way and researches have been gathered according to their orientation in psychotherapy. Three therapeutic orientations are distinguished: the use of technologies as therapeutic objects in themselves (in the manner of serious games); the use of these technologies to facilitate adherence, alliance and therapeutic communication ("relational mediation" caregiver-patient or psychotherapist-patient); the use of video games and robots as cyber-mediations in psychotherapy ("therapeutic mediation" psychotherapist-patient). On the other hand, these three orientations do not seem to occupy the same space within the two levels of functioning in psychotherapy. The difference between the first and third orientations seems to be the systematic presence or not of the psychotherapist. The limitations of this research are numerous, the approach being essentially qualitative and conceptual. Further studies should be undertaken. Additionally, the potential limitations of these uses are highlighted: randomized controlled studies are rare and publications without experimental data are among the most common. Also longitudinal data are lacking, particularly with respect to the maintenance and generalization of results over time. [ABSTRACT FROM AUTHOR]

Cet article propose une revue de littérature concernant l'évaluation et l'efficacité des psychothérapies psychanalytiques et de la psychanalyse (PPP). Après avoir proposé une vue d'ensemble de l'évaluation des psychothérapies, nous reprenons les travaux portant sur l'évaluation empirique et quantitative des PPP avant de nous centrer sur leur évaluation qualitative et processuelle. Les résultats des études menées en ce domaine démontrent que les psychothérapies sont efficaces aussi bien sur le court terme que le long terme. Leur efficacité est le plus souvent indépendante de l'obédience théorique du clinicien. En revanche, les facteurs communs comme l'alliance thérapeutique ou les particularités du thérapeute sont des éléments prévalents de même que la durée et la fréquence des psychothérapies. Concernant plus précisément l'évaluation des PPP, celles-ci sont démontrées empiriquement comme étant efficaces pour la plupart des troubles psychiatriques. Plusieurs caractéristiques des PPP sont en outre corrélées de manière significative avec l'efficacité thérapeutique. L'évaluation qualitative et processuelle des PPP apparaît complémentaire à ce premier niveau d'évaluation empirique qui présente plusieurs limites (biais d'allégeance, indistinction des processus, pratiques de recherches questionnables, etc.) mises notamment en évidence par la crise de la reproductibilité. La méthodologie des Essais Contrôlés Randomisés propose une évaluation de surface à laquelle doivent être associées des approches fondées davantage sur la pratique clinique. L'approche du groupe de Boston, l'analyse des processus psychothérapiques par le Psychotherapy Q-Sort (PQS) ainsi que la modélisation du processus de symbolisation par l'École de Lyon sont trois paradigmes de recherche qualitatifs particulièrement riches de ce point de vue. Les PPP sont efficaces pour la plupart des troubles psychiatriques sur le court terme, en fin de thérapie et plusieurs années après celle-ci. Elles engendrent des transformations durables sur le plan des symptômes et de la personnalité. Elles apparaissent souvent plus efficaces que la pharmacothérapie et conduisent à des économies substantielles quand elles sont mises en œuvre dans des services de soin auprès de patients souffrant de pathologies variées. This article proposes a review of the literature concerning the evaluation and the efficacy of psychoanalytic psychotherapy and psychoanalysis (PPP). After proposing a global overview of the evaluation of psychotherapy, we sum up the empirical and quantitative evaluation of PPPs before focusing on their qualitative and process-based evaluation. Psychotherapies are very effective both in the short and in the long term. Their effectiveness is largely independent of the clinician's theoretical affiliation. Common factors such as the therapeutic alliance or the particularities of the therapist are prevalent, as are the duration and the frequency of the session throughout the therapy. Concerning more specifically the evaluation of PPPs, they have been empirically demonstrated to be effective for most psychiatric conditions. Several characteristics of PPPs are also specifically correlated with therapeutic effectiveness. Moreover, they produce long-term therapeutic effects, particularly concerning personality and after the end of the therapy. The qualitative and process-based evaluation of PPPs appears complementary to empirical evaluation, the latter suffering from several limitations (allegiance bias, indistinction of processes, questionable research practices, etc.) highlighted in particular by the recent crisis of reproducibility. The methodology of Randomized Controlled Trials should be associated with research based on clinical material. The approach of the Boston group, the analysis of psychotherapeutic processes with the Psychotherapy Q-Sort (PQS) and the modeling of the symbolization processes by the School of Lyon are three qualitative research paradigms that are particularly rich from this point of view. PPPs are effective for most psychiatric disorders in the short term, at the end of the therapy, and for several years afterwards. They generate lasting transformations in terms of the reduction of symptoms and of personality evolution. They often appear to be more effective than pharmacotherapy and lead to substantial savings when they are implemented in health care facilities for patients suffering from a large variety of pathologies. [ABSTRACT FROM AUTHOR]

Given the contemporary situation of many analysts in the world now being forced to work online due to the effects of the COVID-19 pandemic, it is important to review the working online issue. Substantial debate over previous years has questioned whether a genuine analytic process can unfold through online work. This debate is reviewed with the conclusion that such a process is not necessarily precluded. Research outcomes are then reviewed to highlight those things that can facilitate positive outcomes when working online. These cover the 'online disinhibition effect', the therapeutic alliance, particular ways of using the screen, focussing on trauma, the importance of self-awareness, knowing the predictors of mental health, certain potential positives of isolation/quarantine and psychotherapy interventions that may be currently needed. Final recommendations and suggestions are then presented as in the diagnosis issue, professional development and guidelines to do with practical and ethical considerations. [ABSTRACT FROM AUTHOR]

As research has shown a consistent link between the alliance and the therapeutic success, an alliance-focused supervision was designed to help novice therapists improve their relational and collaborative abilities. Fifteen young therapists participated in the alliance-focused supervision and 15 did not. Therapists' and clients' results at the Working Alliance Inventory showed that the supervision model improved their perceptions concerning the therapist's ability to foster mutual emotional involvement, as well as collaboration. All therapists demonstrated an ability to negotiate emotional alliance with the client. However, when they participated in the alliance-focused supervision, they appeared to improve their capacity to finding an agreement with the client around therapeutic goals, which was not the case when they did not participate. In addition, more independent views on the alliance appeared in clients and therapists when the professional took part in the alliance-focused supervision than when he/she did not. Results on the Difficulties in Emotion Regulation Scale also showed that participating in the alliance-focused supervision had a protective influence on therapists' impulsiveness. Overall, alliance-focused supervision appeared useful in helping therapists improve emotional involvement and collaboration in the alliance. It also seemed to protect them from being impulsive. [ABSTRACT FROM AUTHOR]

L'épidémie du COVID-19 est survenue au Gabon à une période où l'hôpital psychiatrique vit une crise sans précédent du fait d'une baisse des moyens matériels et humains. À partir de l'expérience clinique des soignants, nous présentons les difficultés que rencontrent ces acteurs du soin pour maintenir l'alliance thérapeutique. L'article expose une synthèse de travaux sur le confinement, le COVID-19 et les troubles psychiques. Globalement, on observe une baisse des consultations en ambulatoire. En zone rurale, la crise sanitaire a occasionné une suppression des suivis au domicile des patients ainsi qu'une difficulté d'accès aux médicaments psychotropes onéreux, favorisant l'inobservance du traitement avec comme conséquence des décompensations psychiatriques. Gabonese psychiatry is facing a crisis, which results in a decrease in material and human resources. Hospital beds are closed and consultations are mainly on an out-patient basis. This article shows how health care workers are coping with this pandemic, and the challenges of maintaining the therapeutic alliance. It presents a synthesis of works on confinement, COVID-19 and mental disorders. Clinical observations reveal that the COVID-19 epidemic has strengthened the dysfunctions observed in care. In rural areas, there is a suppression of follow-up at home. In general, this health crisis had an impact on the purchasing power of patients. What caused a difficulty of payment of the psychiatric consultations in liberal, a difficulty of access to the expensive psychotropic drugs, thus favouring a non-observance of the care, and a decompensation of the psychiatric picture. In urban areas, there is a considerable decrease in out-patient consultations. There is still concern about the inter- and post COVID-19 psychiatric care. This pandemic calls on leaders leading to a reorganisation of the psychiatric care system (decentralisation of establishments throughout the country, training of qualified nursing staff, fall in the prices of expensive psychotropic drugs). The establishment of helplines in psychiatric facilities, the opening of hospital beds, COVID-19 devices in public and private facilities for patients with mental disorders are essential. [ABSTRACT FROM AUTHOR]

In psychotherapy, therapeutic alliance is an integrative factor influencing the effectiveness of treatment. This alliance depends on the bond between therapist and patient. This study investigates patient's psychological variables likely to facilitate or hamper a psychotherapeutic process. We asked 38 clinicians to assess the importance of each domain and facet of the Five-factor model (five domains and thirty facets) supposed to facilitate or hamper therapeutic alliance. Results indicate that high openness, agreeableness and conscientiousness are perceived as favourable to therapeutic alliance. Beyond these results, we preferably focus on facets of the Five-factor model to assess their relevance for the facilitation or hindrance of therapeutic alliance. According to clinicians, 17 facets are supposed to affect positively therapeutic alliance: A2 (straightforwardness), O3 (feelings), C5 (self-discipline), O5 (ideas), O6 (values), C2 (order), O1(fantasy), C1 (competence), E2 (gregariousness), E1 (warmth), A6 (tender-mindedness), N5 (impulsiveness), A3 (altruism), C4 (achievement striving), E4 (activity), N1 (anxiety) and C6 (deliberation). Thirty-eight facets were supposed to have a negative effect on therapeutic alliance: A5 (modesty), A2 (straightforwardness), A1 (trust), C3 (dutifulness), E3 (assertiveness), E1 (warmth), A4 (compliance), O3 (feelings), C4 (achievement striving), N3 (depression), A6 (tender-mindedness), O5 (ideas), A3 (altruism), E5 (excitement-seeking), N5 (impulsiveness), O2 (aesthetics), E2 (gregariousness) and O1 (fantasy). On this basis, we propose three experimental scores investigating the proneness to access therapy based on the Five-Factor Model. [ABSTRACT FROM AUTHOR]

Cette revue de littérature synthétise les résultats des études ayant utilisé une mesure empirique de l'attachement du client au thérapeute en psychothérapie. Une recherche systématique dans les bases de données Medline , Embase , Pubmed , PsycInfo , et Web Of Science a débouché sur 25 études publiées. Une approche méta-analytique a également été utilisée pour examiner la corrélation avec l'alliance thérapeutique (11 études) et l'attachement adulte du client avant la thérapie (11 études). Les résultats montrent que l'attachement du client au thérapeute Sécure est très fortement corrélé à l'alliance thérapeutique, moyennement corrélé aux résultats, et faiblement corrélé négativement aux dimensions d'évitement et d'anxiété de l'attachement adulte. Le style Evitant–Craintif montre des résultats inverse au style Sécure, alors que le style Préoccupé–Fusionnel montre plutôt des corrélations faibles ou nulles, et qui varient suivant les études. Ces résultats sont consistants avec la conception de Bowlby concernant le thérapeute comme base sécure et confirment la pertinence de l'attachement au thérapeute comme prédicteur des résultats et du processus de changement en psychothérapie, pour différentes formes de thérapies et différents types de patients. Attachment theory describes characteristic patterns of relating to close others and has important implications for psychotherapy. Consistent with Bowlby's (1988) secure base conception of attachment in psychotherapy, several instruments have been developed to measure client attachment to therapist. Despite a large number of studies, no review takes into account all published work. The purpose of this systematic review was to compare different measures of client's attachment to therapist, with different groups of client and in different therapeutic contexts. Medline, Embase, Pubmed, PsycInfo, and Web Of Science were searched to identify studies published between 1995 and 2019 reporting on help-seeking client's attachment to therapist. Twenty-five empirical papers met the inclusion criteria. Meta-analyses were conducted for studies that examined client attachment to therapist subscales (Secure, Avoidant–Fearful, Preoccupied–Merger) as correlates of client-rated working alliance (K = 11, 892 clients), and general adult attachment (K = 11, 752 clients). The results show that the client's secure attachment to therapist is strongly correlated with the therapeutic alliance (mean weighted R = 0,71 [95% CI = 0.62–0.79]), moderately correlated with the results, and negatively correlated with the avoidance (mean weighted r = − 0,12 [IC 95% = − 0.06–− 0.21]) and anxiety dimensions (mean weighted R = − 0,11 [IC 95% = − 0.03–− 0.17]) of adult attachment. With the Avoidant–Fearful style, results go in the opposite direction, negatively correlated with the therapeutic alliance (mean weighted R = − 0.55 [IC 95% = − 0.59–− 0.50]), negatively correlated with the results, and correlated with the avoidance dimension of adult attachment (mean weighted R = 0,16 [IC 95% = 0.09–0.23]). The Preoccupied–Merger style shows weak (positive or negative) to zero correlations. In addition, nine studies looked at some dimensions of the psychotherapy process (e.g., resistance, transference, emotions, self-disclosure, and attitude toward psychotherapy), showing that insecurity of attachment to the therapist (both Avoidant–Fearful style and Preoccupied–Merger style) seem to interfere in one way or another with the development of a productive psychotherapy process. Overall, these results are in line with what was expected. They are consistent with Bowlby's conception of a secure base of attachment in psychotherapy. They showed that dysfunction and maladaptive developmental experience interfere with adult's ability needed to establish secure attachments and that psychotherapy may play the role of what has been previously defined as corrective emotional–or intersubjective–experience. In addition, these results do not seem to vary according to the instruments used. Together, the high correlation with therapeutic alliance and the weak correlation with pretherapy adult attachment confirm the relevance of the client's attachment to therapist as a specific variable related to the process of change in psychotherapy. [ABSTRACT FROM AUTHOR]

An heurisitc of the multiple therapeutic alliance's construction during the first hospitalisation of a psychotic emergent episode is developped. The proposition of a multiple therapeutic alliance model is based on empirical researchs and clinical observation. The model describes how multiple therapeutic alliance is created and maintain in four domains: adolescent/young adult, parents, family, outpatients and inpatients psychiatrics teams. The model seeks to describe the evolution of case coordination through three steps: multiple therapeutic alliance's creation during consultation andpre hospitalisation, working the multiple therapeutic alliance during hospitalization, and working with the post hospitalization multiple therapeutic alliance. [ABSTRACT FROM AUTHOR]

The author describes the reflection of the multidisciplinary group on the therapeutic alliance between health care teams and families during a first hospitalization for a psychotic episode. This therapeutic alliance emerges and develops within the framework of the "therapeutic system" constituted by the meeting of two groups: the family group and the "therapeutic team" group gathered around this singular situation, emotionally charged with a psychotic decompensation and the hospitalization of a young person. From this point of view, it is thus a question of moving from the individual logic of medicine to a group logic, from a purely medical reading to a pluriaxial reading. Then, medical knowledge and profane knowledge of the family can be expressed and articulated instead of being opposed. Finally, in this process, temporality, stages and interactivity make it possible to manage the part of diagnostic and prognostic uncertainty that characterizes these situations. This working in alliance makes it possible to avoid disruptions in care and optimizes the therapeutic capacities of the teams and preserves the future. [ABSTRACT FROM AUTHOR]

The article presents the introduction of a dossier that summarizes the questions raised by a multidisciplinary working group, working with the family during the first hospitalization for a psychotic episode. In fact, for the past four years, we have worked out, under the aegis of the French Federation of Psychiatry following a parent's letter, commission work in partnership with UNAFAM. This multidisciplinary working group brought together child and adolescent psychiatrists, adult psychiatrists, psychologists of various backgrounds and working in different care contexts, nurses, general practitioner and a regular member of UNAFAM. We are pleased to present the first results of this work initiated by Dr. Roche-Rabreau whose article appears in this dossier. We would like this work to allow the development of recommendations for good practice, such as those developed in different aspects of psychiatric practice. In the appendix, we have set out a summary of the recommendations worked out in committee, and presented during various psychiatric manifestations as well as to the French Federation of Psychiatry. [ABSTRACT FROM AUTHOR]

Pendant longtemps, le psychotraumatisme est resté l'affaire des médecins militaires. Les derniers attentats sur le sol français et le nombre important de personnes ayant développé un trouble de stress post-traumatique ont depuis ouvert la voie à de nouvelles approches dans la prise en charge. Cet article étudie par quels processus et dans quelle mesure un atelier d'art-thérapie par l'argile peut aider les personnes ayant subi un traumatisme. Comment l'argile, en tant que médium malléable, peut-elle contribuer au processus de changement dans un cadre thérapeutique ? Peut-elle favoriser l'élaboration du vécu PTSD ? L'argile permettrait un premier temps une voie cathartique nécessaire, suivi d'un deuxième temps d'élaboration et d'un troisième de transformation. Ces trois étapes sont-elles garantes d'un pronostic positif lors d'un PTSD ? Ce travail prend en compte l'importance de l'alliance thérapeutique entre thérapeute et participant. Cette relation est construite autour d'un cadre contenant et structurant qui permet au processus de création de se mettre en place. The purpose of this paper was to review of the benefits of art therapy in the management of post-traumatic stress disorder (PTSD). Psychotrauma has long been the business of military doctors. However, the latest attacks on French soil have opened the door for new approaches in care. Research in clinical psychology and psychopathology underlines the effectiveness of art therapy in the treatment of PTSD. Our aim is to identify the extent to which and the processes through which clay may be of benefit to people having suffered trauma. As a malleable medium, can clay contribute to the process of change in a therapeutic setting? Can it help the patient confront trauma-related information in a therapeutic manner? Clay is a vehicle that allows for three steps in the therapeutic process. First, clay allows for a cathartic release of emotions. Second, it helps elaborate the traumatic experience. Third, it leads to transformation. Do these three steps guarantee a positive prognosis for PTSD? This work takes into account the importance of the patient-therapist therapeutic alliance. This relationship, built within a structured and containing therapeutic framework, allows the creative process to take place. Art therapy with clay helps reduce anxiety. The act of kneading, smoothing, touching, or moistening the clay, makes artistic creation a pleasant and relaxing activity. This induces relaxation and the reduction of cortisol levels, reducing stress and anxiety. This relaxation is comparable to that achieved through mindfulness. Clay makes the unconscious visible and thus creates possibilities for investigating emotions and cognition. This contributes to cognitive regulation. Varying instructions during the sessions allow the participant to learn to self-regulate through touch, and control physical reactions that trigger the cycle of stress. Work with clay provides distance, improved recall of trauma and easier access to emotions. The setting, instruction, and attitude of the therapist create a safe environment for the conscious expression of emotions and memories. This is similar to exposure, recall, and emotional distancing and allows for better regulation of emotion. Clay facilitates the association of ideas. It helps the patient open up to his therapist and their experience during the process of creating with clay can be deepened through conversation. After identifying and isolating negative thoughts, patients gain new skills on how to counteract them. Clay allows the elaboration of thought and improves the capacity for symbolization and imagination. The results presented in this article provide insight into the effectiveness of clay art therapy in trauma treatment. They highlight the urgent need for further research on art therapy and trauma treatment. [ABSTRACT FROM AUTHOR]

Résumé Objectif Explorer la relation médecin-patient dans les études qualitatives traitant de la théorie de l'attachement, qui en apportent une compréhension en médecine générale. Méthode Méta-synthèse : méthode d'analyse secondaire d'études qualitatives. Revue de littérature, analyse thématique, translation et synthèse. Résultats La relation médecin-patient était une relation d'attachement nécessaire au patient pour se sentir apaisé en situation de vulnérabilité. Les stratégies de régulation des émotions négatives du patient et du médecin guidaient les comportements de santé. Le propre style du médecin conditionnait la qualité de la relation. Le médecin, « base sécure », exerçait un effet régulateur des émotions négatives du patient. La confiance mutuelle était thérapeutique dans une approche « liée-patient ». Conclusion La théorie de l'attachement est utile pour l'étude de la relation médecin-patient. Abstract Objectives Explore the physician-patient relationship through the qualitative studies about attachment theory, to allow its understanding in general practice. Materials and methods Meta-synthesis is a method of secondary analysis of qualitative studies. The studies had to be about attachment theory, applied to the framework of the physician-patient relationship in general practice. Studies were identified and selected in MEDLINE, EM Premium, Banque de Données en Santé Publique, PsyclINFO, PsycARTICLES, Web of Science. The quality of the studies was evaluated thanks to the CASP qualitative research checklist. Three researchers performed a thematic analysis and then a reciprocal translation of different themes across studies. A triangulation was performed at every step. The synthesis was written according to the ENTREQ reporting guidelines. Results 14 studies have enabled a lines-of-argument synthesis with 6 master themes. The physician-patient relationship in general practice was an attachment relationship. This relation was necessary for the patient to feel safe in a situation of distress. The physician and his patient had strategies of regulation of negative emotions. These internal working models guided health-behaviours, like the engagement in their relationship and the approach of each of them. The own physician's attachment style on the one hand, and his reflexive function on the other hand, influenced the quality of the relationship with his patient, favoring therapeutic alliance. Being a secure base for the patient involved the regulation of his negative emotions. Patient-centered care could be revisited as informed by adult attachment theory. The approach including a patient's attachment style, but also that of a physician, has been defined as "an approach linked to the patient". The mutual trust in each other was therapeutic. Conclusions General practice could inspire itself from this useful framework to understand interpersonal difficulties and improve care. More research is needed to explore specific components, such as doctor's attachment style, its complementarity with patients' styles, or the reflexive function as a mediator of this relationship. [ABSTRACT FROM AUTHOR]

This study examined how clients' self-image and perception of therapist's behavior are related to the therapeutic alliance, as well as how these variables change in the psychotherapy process in trainee-led psychotherapy. A total of 164 participants (M = 28.9 years) who attended two semesters of treatment at the Psychology Clinic of Umeå University completed the Working Alliance Inventory (WAI) to evaluate their perception of their alliance with the therapist. They also completed two questionnaires based on the Structural Analysis of Social Behavior (SASB) model to give insight into their self-image patterns and to analyze their perceptions of the therapist's behavior. The results show that a positive self-image and positive perceptions of the therapist's actions increased significantly over the course of the therapy, with a corresponding decrease in negative patterns. The alliance scores show that the therapeutic alliance gains significance over time and that it is influenced more by the perception of the therapist's behavior than by the self-image. The self-image becomes relevant after the mid part of therapy, underlining the role of the therapist in co-creating the treatment relationship. The implications of these results are discussed, and so are directions for future research in other trainee-led settings and samples. [ABSTRACT FROM AUTHOR]

Résumé Objectifs Les sujets ayant un trouble de la personnalité borderline sont peu informés sur leur trouble, malgré les recommandations en ce sens. Nous n'avons pas retrouvé de document d'information écrit sur le trouble élaboré en collaboration avec des patients, comme le préconise la Haute Autorité de santé. L'objectif de ce travail a été d'élaborer et d'évaluer un document d'information pour les personnes ayant un trouble de la personnalité borderline, en impliquant des patients. Méthode Nous avons organisé un groupe de travail puis des entretiens individuels avec des patients. L'évaluation a été quantitative et qualitative (analyse thématique). Résultats Une version initiale du document a été élaborée à partir de différentes sources récentes. Le groupe de travail a conduit à 19 modifications du document, dont l'ajout d'une partie « d'autres pistes pour aller mieux » et l'ajout de la notion d'hypersensibilité. Les entretiens individuels ont conduit à 23 modifications, dont la suppression des pourcentages sur l'évolution du trouble (devant leur caractère pessimiste), le développement du critère sur l'instabilité affective (considéré comme central), le développement de la partie « autres pistes pour aller mieux » (avec des conseils de gestion de l'anxiété). Les patients ont évalué le document facile à comprendre, intéressant, et sa lecture a été bien vécue. En revanche, la présentation a été jugée insuffisamment attractive et a été améliorée. Conclusion Ce document a pour objectif d'être utilisé en complément de l'information orale, qui reste indispensable. Il serait intéressant d'évaluer l'impact de l'information orale et écrite sur l'alliance thérapeutique. Abstract Introduction Borderline personality disorder affects 10% of ambulatory patients and 15 to 25% of patients hospitalized in psychiatry. Therapeutic recommendations include informing patients about the characteristics of the disorder, its evolution and the effectiveness of psychotherapies. This information can promote self-understanding, therapeutic alliance and the involvement of the patient in his/her care. Despite these recommendations, people with borderline personality disorder are generally not well-informed about their disorder in France. We find a few written document delivering information about the disorder destined for patients in French, but we did not find it with a detailed elaboration methodology and none developed with patient involvement. The objective of this work was to develop and to evaluate, an information leaflet for patients with Borderline Personality Disorder, involving patients in these two stages. Method We developed and evaluated an information document with a step-by-step approach, similar to that described in the methodological guide of the French High Authority for Health (Haute Autorité de santé). We first designed an initial version, which we then modified with a working group with 4 patients and 2 health professionals. Finally, we evaluated and modified this document through 6 individual interviews with patients. Patients were recruited through psychiatrists and psychologists from the department of Toulouse, who were contacted by email. Concerning the analysis of the data, the answers to the closed questions were quantified. The answers to the open-ended questions were analyzed qualitatively through a thematic analysis, in order to organize in a structured and synthetic way all the subjects covered by the patients during the various interviews. Results The working group led to 19 changes to the original version of the document, including the addition of "other ways to feel better", the addition of the concepts of hypersensitivity and intense emotional crisis, and rewording to simplify the document. Individual interviews led to 23 changes including: the removal of percentages on the evolution of the disorder (in view of their pessimistic nature), the development of the criterion on affective instability (considered as central), the development of the "other ways to get better" section (with a crisis management board through a soothing activity); several rephrasings, reorganizations or deletions. Patients evaluated the document, they judged it as easy to understand, interesting and its reading was well experienced. On the other hand, the presentation was judged to be insufficiently attractive and is being improved by graphists. We can emphasize the particular attention shown by the patients to the document being optimistic. Conclusion We have elaborated with patients an informative document. This document is to be used as a support to oral information, in order to reinforce the patient's knowledge. It cannot replace the oral information that remains essential. Concerning the limitations of this work, it might have been interesting to involve other health professionals in the development of the initial version of the document, such as experts on the disorder. It would be interesting to evaluate the impact of the information approach on the therapeutic alliance or the involvement of patients in care, as well as the impact of the written document on these parameters. [ABSTRACT FROM AUTHOR]

The work with parents has always characterized the institutions that deal with psychological treatment of children. Family therapy has evolved a lot and, differently from the therapy with groups of parents, it has relied on a strong theoretical basis. The groups of parents, instead, work above all as "groups of words" that support the Ego function. In this article, I address questions on the setting and the therapeutic process that is involved in this kind of group through the discussion of a clinical vignette. [ABSTRACT FROM AUTHOR]

Abstract: For some time, it has been clear that psychoanalytic theories are built upon the kind of master narratives Roy Schafer, a New York psychoanalyst, described in 1980. As such, psychoanalytic theories may today have lost some of their initial scientific credibility in that they can no longer be seen as summarizing findings from data collected in a research environment. As aids in participating in their patients’ process of healing, however, narratives continue to be used by practitioners and reflect allegiance to core beliefs and propositions with roots in long‐standing Western thought. In this article, the metaphors in master narratives of Freud and Jung are compared with a conceptual system identified by cognitive linguists as ‘The Great Chain of Being’. Based on this analysis, the article proposes that theoretical formulations have mainly a secondary role to play in achieving good outcomes. The most critical element is the therapist's capacity to access a specific narrative for what transpires throughout each treatment. [ABSTRACT FROM AUTHOR]

Intersections between Grawe’s General Psychotherapy and Prochaska’s Transtheoretical Model were investigated in group therapy in a longitudinal design. It was assumed that general change mechanisms have an impact on patients’ stages of change. Specifically, the main hypotheses were that experiential change mechanisms (ECM; clarification of meaning, problem actuation, emotional bond and group cohesion) should be especially relevant for early stages of change (precontemplation and contemplation), whereas behavioral change mechanisms (BCM; resource activation, mastery/coping and task and goals) should be especially relevant for late stages of change (action and maintenance). Therefore, 140 outpatients attending different types of group therapy, with a typical duration of 8 sessions, were investigated. Patients completed the Form for the Evaluation of Therapeutic Processes in Group Therapy (FEPiG), the University of Rhode Island Change Assessment, short version (URICA-S) and several symptomatology measures (BDI-II, BSCL and IIP-32) at two measuring times. Intersections were analysed through correlational analyses, cross-lagged panels and a path-analytic model, supporting the hypotheses. Specifically, results suggested that experiencing ECM at t1 predicted higher levels of reported contemplation at t2. Patients experiencing higher levels of BCM at t1 reported higher levels of action at t2. Clinical implications of the results are discussed. [ABSTRACT FROM AUTHOR]

Résumé Le soin est indissociable de la relation de confiance et de la mobilisation de la capacité du patient à exprimer librement ses choix et de participer aux décisions le concernant, aptitude centrale dans la relation de soins. Si les objectifs d’accès aux soins et de protection des droits du patient sont clairement posés, la question de la liberté de choix du malade mental reste sujette à caution, notamment dans le contexte de la sectorisation psychiatrique. En France, les textes législatifs ne définissent pas de claire délimitation entre l’incapacité à consentir aux soins, le refus de soins et l’adhésion à ces derniers. Il revient par conséquent au médecin de déterminer dans chaque situation si le patient est en état de consentir et d’en apporter la preuve. Le consentement, valorisé par notre moderne démocratie sanitaire, est contesté par le besoin de sécurité mentale, mais conforté par la recherche d’alliance thérapeutique. La permanence d’une telle situation conflictuelle rend compte d’un affrontement entre la défense des droits de l’homme, ici et maintenant, et l’affirmation du « libre choix » de la société. We cannot separate a relationship's care based on trust from the raising of patient's ability to freely express his decisions, the core capability of health relationships. If the goals in access of care and patient's rights protection are clearly laid down, the issue about the freedom of choice of the mentally ill person is still subject to caution, particularly in the context of the psychiatric division into sectors. The French legislative texts do not specify a clear boundary about the inability to consent to the care and it is up to the doctor to approve of its validity. The consent, valued by modern sanitary democracy, is disputed by the need for mental security but is consolidated by the search for a therapeutic alliance. The permanence of a conflicting situation explains the confrontation between a defense of the human Rights, hic and nunc, and a free choice assertion by the society. [ABSTRACT FROM AUTHOR]

Résumé Les directives anticipées sont des documents écrits permettant à une personne consciente de formuler à l’avance ses demandes concernant les soins médicaux futurs, pour le cas où elle serait dans l’incapacité de donner son consentement. Les directives anticipées appliquées à la prise en charge des troubles psychiatriques revêtent des caractéristiques bien spécifiques. Proches de concepts récents tels que l’ empowerment et le rétablissement, elles permettent au patient d’exprimer ses demandes de prise en charge en cas de rechute. Elles ont pour objectif de favoriser l’implication du patient dans ses soins et valorisent son autonomie. Les directives anticipées psychiatriques constituent une intervention complexe, dont les données de la littérature reconnaissent l’intérêt, mais dont la mise en place se heurte à des obstacles pratiques. En s’appuyant sur les résultats existants, notre équipe propose un modèle de directives anticipées psychiatriques appelé Plan Souhaité d‘Organisation des Soins (Plan SOS), appliqué à la prise en charge de patients atteints de pathologies psychotiques chroniques et intégrés aux soins de secteur. Il s’inspire du Joint Cris Plan développé au Royaume-Uni et a la particularité d’associer l’équipe de soins, les proches ainsi qu’un médiateur extérieur à la prise en charge à la rédaction du document avec le patient. Actuellement développé dans le cadre d’un protocole de recherche national multicentrique, les données concernant l’efficacité clinique du Plan SOS sont à venir. Objectives Psychiatric advance directives (PAD) are written documents which are used for patients to notify in advance their preferences for psychiatric treatment for a future situation of relapse when they are unable to give their consent. It contains his or her treatment preferences for any future psychiatric emergency, when he or she may be too unwell to express clear views. The hypothesis is that such active involvement by the patient in the process of crisis planning will increase the likelihood of averting major relapse and the need for compulsory detention. Materials and methods This article reviews the current state of knowledge on use of PAD and then explains the propositions for developing a new model of PAD in France. Results Many studies show a real interest for PAD, regarding user's autonomy, therapeutic alliance and diminution of coercion. PAD may contain information about medication, symptoms, non pharmaceutical demands, name of a proxy decision maker. Different types of PAD exist, depending on the number of stakeholders involved in their completion. Despite a lot of promises, implementation of PAD remains difficult. We define the Plan SOS as a new model of PAD, inspired by the Joint Crisis Plan. It's based on the completion with the user, his medical team, his family and the presence of a facilitator, of an advance care planning. Conclusion Plan SOS is so far a research intervention and a current study is taking place to explore effect of Plans SOS on number of hospitalisations, clinical state, and therapeutic alliance. [ABSTRACT FROM AUTHOR]

Résumé L’observance du traitement antipsychotique est souvent faible. Ainsi, deux tiers des participants arrêtent le traitement dans les protocoles d’évaluation clinique en raison de problèmes de tolérance ou d’efficacité. Dans les années 1980, des études ont montré l’intérêt et les limites des méthodes alternatives au traitement antipsychotique de maintien comme le traitement intermittent ou le traitement prophylactique avec des doses minimales. Néanmoins, ces alternatives ont été largement délaissées en raison de leur efficacité relative, ce qui tend à limiter les choix thérapeutiques au maintien d’un traitement antipsychotique aux doses utilisées en phase aiguë. Cette attitude peut interférer avec la relation thérapeutique et nuire à l’appropriation du traitement par les patients. Le but de cet article est de discuter la recherche d’un dosage minimal comme méthode psychiatrique et psychothérapeutique pour améliorer l’ insight , l’observance du traitement et l’alliance thérapeutique, ainsi que de favoriser le rétablissement, la gestion autonome de la santé et la réduction des effets secondaires tout en évitant les conséquences négatives du risque de rechute. La recherche d’un dosage antipsychotique minimal reste controversée, mais repose sur des bases scientifiques telles que les notions de saillance aberrante ou de taux d’occupation des récepteurs dopaminergiques D2 et bénéficie d’un regain d’intérêt, en particulier pour les premiers épisodes psychotiques. Objectives Antipsychotic medication compliance is low. In the 1980s, studies have shown the value and limitations of alternative methods to continuous standard antipsychotic treatment as intermittent medication or low doses. However, these alternatives were largely abandoned because of their controversial efficacy. Having only one option for maintenance treatment limits treatment choices and constrains therapist's attitude toward maintenance medication at the dosage, which was necessary in the acute phase. This may cause symmetrical relationships with patients, and limits shared decision-making, working alliance and patients’ empowerment to manage medication. The purpose of this article is to discuss the search for a minimal dosage as a psychiatric and psychotherapeutic intervention to improve insight, treatment adherence and therapeutic alliance and to promote recovery, self-management of health, while reducing side effects and avoiding the negative consequences of relapse. Material and methods Development of intervention was based on a literature review focused on shared decision-making, relapse prevention and alternatives to maintenance antipsychotic medication. A clinical vignette illustrates the intervention. Results The recovery process needs patient's hope and taking his/her own responsibilities over the management of disease. This is not possible into a compliance paradigm that implies obedience to medical orders. Working alliance, which is one of the best predictors of outcome in psychotherapy, must also become a goal in psychiatric treatment. Moreover, without treatment choices, there is no room for shared decision-making for both patient and therapist. There is thus a need to shift paradigm in order to open choices for antipsychotic treatment beyond continuous maintenance at standard dosage. A new paradigm may be based on several rational arguments. First, a different conception of relapse is necessary. Linear vision of recovery does not match the experience of individuals: knowledge and mastery of disorders often go through the experience of relapse. While relapses may indeed have harmful consequences when they lead the person into a vicious circle of failure, trauma and rejection of treatment, a well-controlled relapse before a full psychotic episode may be an opportunity to know more about the early signs and management of the disorder in a virtuous circle. Second, recommendations of maintenance treatment for several years are based RCTs, which are limited by on short-term follow-up and high rates of discontinuation due to both efficacy and tolerability problems. Third, several studies showed that patients receiving half standard dosage (about 300 mg EQ CPZ) had no more relapse, less side effects, and better social outcomes. Forth, even if maintenance treatment is the best way to prevent relapse for most individuals, the burden of this treatment remains high for individuals. There is therefore a need to detect those who could remain stable with low dosage, very low prophylactic dosage, intermittent treatment or without treatment. A recent meta-analysis shows that relapse is 2.5 times more frequent in the intermittent treatment with respect to continuous treatment. The discontinuous treatment may also cause sensitization and increase the risk of tardive dyskinesia. These observations led in general not to propose alternatives to continuous treatment in clinical recommendations. However, intermittent treatment remains significantly more effective than placebo, with three times fewer relapses at medium-term. The population of people diagnosed as having schizophrenia is heterogeneous and in some studies, 20%–40% of patients could benefit from a full stop of medication without relapse. In early psychosis, intermittent treatment can detect 20% of patients who can stop the antipsychotic treatment without relapse. Even for those who relapse, the process could have a long-term positive effect on social functioning. Patient adherence to treatment was also higher during intermittent therapy, and the cumulative dose of antipsychotic lower. At last, neuroscience issues such as aberrant salience and dopamine D(2) receptor occupancy give a biological theoretical background to the search of an optimal dosage of antipsychotics. Finally, the therapeutic relationship should go beyond mere prescription of drug, when some patients and therapists confuse “withdrawal of antipsychotic medication” with “discontinuation of treatment”. On the contrary, in view of the search of a minimal dosage, the desire to stop antipsychotic treatment is rather a psychotherapeutic opportunity to develop insight, the ability to identify early signs relapse and to enhance working alliance in a shared decision-making process. Conclusions The search for a minimal dosage of antipsychotics in psychosis remains controversial but feasible, scientifically sound and especially recommended for first-episode psychosis. It assumes that the doses needed for prevention of relapse are lower than in the treatment of an acute episode. Process should be considered with caution and at a slow pace, particularly when the desired dosage reaches 300 mg CPZ EQ or leads to a complete interruption of treatment. The counter-indications include non-stabilized symptoms, dangerousness, a history of severe social consequences or a lack of cooperation with the patient and relatives. The potential consequences of relapse must be carefully examined with the person and family. A short delay between the early signs and full psychotic episode is a relative contraindication, especially if previous episodes have significant risks for the person or to others or had serious social consequences. Further studies should determine more precisely who could benefit from such an approach beyond first psychotic episode, in order to offer other choices to individuals than stopping medication against their therapist's advice. [ABSTRACT FROM AUTHOR]

The REVHEPAT network designed an outpatient therapeutic education program (TEP) for patients with chronic hepatitis B and or C to optimize their care pathway. This program is part of the 3 stages of the life of the patient and his relatives before, during and after the treatment, on the basis of collective workshop. This is an innovative approach to chronic liver disease with 562 patients. The collective workshop is a space to understand the subjective experience of illness. It allows resorting to listening, what is seen and felt to overcome the difficulties in communicating about the disease and combining the complex and the intimate. The therapeutic alliance is improved thanks to a newposture of caregivers increasing their knowledge (do/be), for better prevention. The coordination of actions between therapeutic hepatologist and the general practitioner or care structure is reinforced by the TEP team. The collective workshop brings added value to patients. It is a real level that patients can seize to take care of their health, learning how to act on comorbidities and associated risk factors. Thereby, 69 collective workshops have been conducted in 2015. It is a key and a supportive 'tool' with a collective dimension at the person's service (not only focused on the liver). [ABSTRACT FROM AUTHOR]

Previous literature suggests that music therapy can be an effective psychosocial treatment for solid organ transplant patients, but there is a lack of research concerning how guitar accompaniment style might impact aspects of the therapeutic relationship. The purpose of this study was to determine the effects of guitar accompaniment style on working alliance, session impact, and pain with hospitalized solid organ transplant patients. In this single-session study, participants (N = 20) were randomly assigned to either a music therapy intervention with simple guitar accompaniment (SGA) condition or a similar condition with complex guitar accompaniment (CGA) and then completed a questionnaire measuring working alliance and session impact. Analyses indicated significant between-group differences in the positivity and arousal subscales of the session impact measure, with participants in the CGA condition having more favourable scores than participants in the SGA condition. Although there was no significant between-group difference in other measures, there tended to be slight mean differences consistently favouring the CGA condition. Overall results indicated that music therapy intervention with CGA had slight tendencies to impact working alliance, session impact, and pain more positively than with SGA. Limitations, implications, and suggestions for future research are provided. [ABSTRACT FROM AUTHOR]

Only 11 per cent of chronically sick adolescents have a good adherence at all aspects of their treatment. What sense takes the medication for the adolescent? What meanings can have certain behaviors of young people about their treatment? What role for parents in the prescription to the adolescent? In these issues, which place for the child psychiatrist? Especially in adolescence, adherence refers to paradoxical attitudes that are a consequence of the complex issues of mental maturation at this age. The therapeutic alliance, with both the adolescent and his parents, seems to be a prerequisite for good adherence, which is always a compromise between medical logic and logic of the subject. Situations of rupture and adherence or, conversely, of excessive adherence, should always alert and it is important to decode the meaning of these behaviors. Rather than seeking the perfect observance, it is preferred the establishment of a care relationship in which the adherence can be addressed calmly and openly with both the adolescent and his parents. [ABSTRACT FROM AUTHOR]

Résumé Le recueil sémiologique en psychiatrie nécessite : un cadre conceptuel dans lequel les termes sémiologiques sont recueillis et organisés d’une manière cohérente et une pratique clinique permettant d’acquérir les compétences nécessaires au cours de l’entretien avec un patient. Les symptômes concernent différentes dimensions de l’expérience vécue et des conduites du patient. Les symptômes sont donc particulièrement liés à la situation dans laquelle le sujet vit. Ainsi le médecin, pour recueillir ces symptômes, devra s’intéresser de manière attentive à cette situation de vie afin de recueillir une sémiologie valide. Cet intérêt et attention ne s’improvisent pas. Un ensemble de compétences relationnelles sont nécessaires au cours de l’entretien afin d’obtenir la confiance du sujet. La mise en confiance du patient passera par un processus appelé « engagement ». Ce processus d’engagement conduit à ce qui est traditionnellement appelé une alliance (qui est donc le résultat du processus d’engagement). Afin de réussir le processus d’engagement, le médecin devra essayer de répondre à quatre questions que le patient pourrait se poser : ce médecin me comprend-il ? Ce médecin me juge-t-il ? Ce médecin est-il sympathique ? Ce médecin est-il compétent ? À chacune de ces questions correspond une compétence relationnelle de la part du médecin : l’empathie, le sentiment de sécurité, l’authenticité, la compétence. Cet article présentera ces quatre éléments dans le cadre d’un modèle médical pratique permettant un recueil sémiologique valide. The semiologic collection requires in psychiatry: a conceptual framework in which the semiologic terms are collected and organized in a consistent way and a clinical practice to acquire the necessary skills during the interview with a patient. Symptoms affect different dimensions of the patient's experience and behavior. The symptoms are particularly associated with the situation in which the subject lives. Thus, to collect valid symptoms, the physician should be attentively interested to this situation of life. This interest cannot be improvised. A set of interpersonal skills is required during the interview to obtain the confidence of the subject. The building of patient confidence is a process called “engagement”. This engagement process leads to what is traditionally called an alliance (which is the result of the engagement process). In order to succeed the engagement process, the physician will try to answer 4 questions that the patient might ask: does this doctor understand me? Does this doctor judge me? Is this doctor friendly? Is this doctor competent? Each of these issues is a relational competence of the physician: empathy, sense of security, authenticity, and competence. This article will introduce these four elements as part of a practical medical model to a valid semiologic psychiatric collection. [ABSTRACT FROM AUTHOR]

While therapeutic alliance formation has been widely researched over many sessions of psychotherapy, the question of alliance formation in short-term counselling has been less explored. Given the increasing evidence in the literature for the positive impact of alliances on therapy outcomes, providing counsellors – who may work with clients for a limited number of sessions – with enhanced insight into alliance formation will be of value. This qualitative study investigated the experiences of eight counsellors forming alliances with clients over short periods. Semi-structured interviews were analysed using interpretive phenomenological analysis. Five major themes emerged, that while congruent with the alliance literature, add some details relevant to day-to-day practice. These themes included: the importance of strong alliances; the need for psychologically comfortable environments; the timing of alliance formation; and the impact of counsellor personal qualities – such as being real – in strengthening and maintaining alliances. In addition, an unexpected sixth theme revealed that body language was highly valued as an indicator of strong or weak alliances. Implications for increasing the use of body language to enhance counselling practice and education are discussed. [ABSTRACT FROM AUTHOR]

Résumé Principalement abordés sous l’angle médical et physiologique, les traitements de l’obésité et l’embonpoint ne permettent pas de faire état de toute la complexité de ces problématiques. Les recherches dans le domaine de la perte de poids ont montré une relation significative entre l’obésité et certaines variables psychologiques. Ces facteurs psychologiques, dont le lien avec l’obésité et l’influence sur la perte de poids ont été démontrés, semblent être liés à l’alliance thérapeutique, une variable très étudiée dans les recherches portant sur le processus et les résultats thérapeutiques. Dans le domaine des traitements pour la perte de poids, peu d’études ont porté sur cette question. Au moyen de modélisation par équations structurelles multiniveau (MESM), la présente étude a examiné les changements dans l’interaction entre l’alliance thérapeutique, l’état de préparation psychologique et le poids. L’étude a été conduite auprès de 105 sujets âgés de 20 à 65 ans avec un indice de masse corporelle (IMC) d’au moins 25 kg/m 2 . Les résultats indiquent que l’alliance thérapeutique agit sur la perte de poids à travers des effets interactifs, alors que le changement de l’état de préparation psychologique prédit la perte de poids. Les limites et les contributions de cette recherche sont discutées. Objectives The study of factors involved in the process of weight loss is of great interest to researchers. Specialists in the domain of weight management encourage the reduction of calorie intake by the change of eating habits, physical exercise and in certain cases of morbid obesity, by bariatric surgery. Most often the treatment of weight loss is perceived and addressed mainly from the medical and physiological perspective; obesity and overweight are considered in terms of surplus fat that may increase the risk of harmful health consequences. However, considering the problem of excessive weight and its treatment as only a biological issue fails to grasp the complexity of the issues. Research in the field of obesity has shown a significant relationship between obesity and psychological difficulties. These psychological factors appear to be related to a variable that has been extensively studied in research on psychotherapy process and outcome, namely the therapeutic alliance. However, in the field of weight management, few studies have addressed this issue. Thus, the present study aimed to investigate the interaction between development of the therapeutic alliance over the course of weight loss treatment, along with changes in psychological variables and weight loss. Method The study was conducted among 105 subjects aged between 20 and 65 years (42.94 ± 12.17 years) with a Body Mass Index (BMI) of at least 25 kg/m 2 (31.83 ± 5.44 kg/m 2 ). The French version of the shortened Working Alliance Inventory (WAI) and the Larocque Obesity Questionnaire (LOQ) are the main measuring instruments. Their administration was carried out online after each consultation for the WAI and just before the meeting with the doctor for the LOQ. Results Multilevel structural equation modeling indicated the importance of studying the complex interaction between the therapeutic alliance and psychological variables in the treatment of overweight. Specifically, the results showed that changes in psychological readiness predicted weight loss. However, contrary to predictions the therapeutic alliance did not directly predict improvement in psychological readiness, or weight loss. Therapeutic alliance seemed to act more on weight loss in interaction with psychological readiness. Conclusions These results shed new light on the treatment of obesity and overweight. They pave the way for treatments directed more towards the process of treatment for obesity rather than the simple result of losing the excessive weight through biological means (i.e. diet and exercise prescriptions). They suggest the importance of developing interventions aimed at improving the psychological readiness of patients since lack of readiness could jeopardize the patient's achievement of their objectives. Finally, the results of this study support the need to deepen our understanding of the role of the therapeutic alliance in the treatment of obesity and overweight, since it is strongly and significantly related to psychological variables predicting weight loss. [ABSTRACT FROM AUTHOR]

Résumé La thérapie interpersonnelle est une thérapie brève, limitée dans le temps, développée à la fin des années 1970 et présentée dans un manuel en 1984 par G. Klerman. Elle a fait l’objet de nombreuses validations et elle se trouve dans les recommandations internationales en tant que traitement actif de la dépression. Pourtant, elle reste peu connue. L’une des raisons de cette diffusion limitée pourrait être en lien avec ce manuel qui semble surtout adapté à la recherche. De même, la théorie de l’attachement, qui représente la base conceptuelle de référence pour la thérapie interpersonnelle, n’est pas abordée au niveau du processus thérapeutique. Or, plusieurs études ont démontré que les styles d’attachement sécures expliquent en grande partie la qualité des relations interpersonnelles et le bien-être psychologique que les individus en retirent. En outre, l’attachement est de plus en plus présent dans des approches différentes, aussi bien longues que brèves, dans la mesure où il ouvre des perspectives thérapeutiques très prometteuses. L’objectif de cet article consiste à expliquer en quoi l’intégration du concept bowlbien à la thérapie interpersonnelle classique apporte un éclairage permettant de mieux appréhender les décompensations dépressives en lien avec les dysfonctions interpersonnelles. Dans cette optique, nous proposons de présenter notre modèle basé sur l’attachement comportant une articulation psychopathologique et clinique ainsi qu’une régulation émotionnelle interpersonnelle comme levier thérapeutique. Interpersonal therapy is a time-limited brief therapy, developed in the late 1970s and manualized in 1984 by G. Klerman and his collaborators. Although recognized as one of the theoretical foundations of interpersonal therapy, attachment theory has been under-exploited in practice. The aim of this paper is to present our model based on attachment theory with a psychopathological, clinical and therapeutic integration in line with the needs of a brief approach. Our model relies on the hypothesis that an insecure attachment style is a risk factor for psychiatric disorders. Indeed, Bowlby's model enables for a better understanding of these relationships and proposes a therapeutic approach based on the patient's attachment needs. In practice, the therapy is structured over a period of 12 to 16 weekly sessions. Our contribution to classical interpersonal therapy, during the initial phase, is the evaluation of the patient's attachment style by reviewing the early experiences of attachment, interpersonal and romantic attachment. In parallel, we review all the depressive symptoms and explore life events surrounding their onset in order to identify the interpersonal problem area on which will focus the therapy: Grief, interpersonal disputes, and role transition. In our approach, interpersonal disputes are explored through emotionally charged incidents in connection with avoidance and anxiety dimensions assessed with the Experience in Close Relationships Scale. During the intermediate phase, therapeutic work is to solve the patient's interpersonal problem by helping him to re-evaluate his expectations in terms of attachment through a number of techniques. These are focused on a therapeutic relationship as a secure base, interpersonal emotional regulation and interactional regulation. The final phase closes the therapy and helps the patient to review his progress and to plan the future. It is important to prepare the end of the therapy with the patient, as it can be experienced as abandonment, especially for those with an anxious attachment style. [ABSTRACT FROM AUTHOR]

Abstract: The therapeutic alliance defines the mutual collaboration, a partnership, between the patient and the therapist with the aim of achieving the fixed objectives. This concept originated in psychoanalysis, and gave rise to intense debates. We propose a synthesis of these debates, since the first intuitions of Freud until the concept of intersubjectivity. This allows to update the arguments of a question which is not finally cut, but which finds however a way of expression in the researches concerning the analytical brief therapies. Indeed, the confrontation of idea essentially carried around the fact of knowing if the notion of therapeutic alliance was antinomic of the concept of transference. And if it was not, how it was possible to integrate it into analytical follow-ups (in premises or in complementarity with an analysis of transference movements). The question is not concluded, but if we consider that although it arrives, a certain collaboration is established between the patient and his therapist, then an analysis of this collaboration via the notion of therapeutic alliance is possible and can offer a glance on the relational dynamics independently of the question of the analysis of transference. It is this verse which the current researches around the therapeutic alliance from analytical follow-ups. [Copyright &y& Elsevier]

It is a certified fact that the therapeutic meeting psychoanalyst-patient during the preliminary interview engages the protagonists in an explicitly convergent intercession, an agreement in the conscious register for a joint effort that aims to cure suffering and ameliorate self-knowledge. This facet of the relation defines the therapeutic alliance. However, what happens in parallel, in the subsurface of the meeting implies, likewise from the beginning, the more cryptic register of the unconscious, subtly looms in both the patient's precocious transferential movements and in the therapist's countertransference response. The paper, centered mainly on the latter aspect, sets to give a possible answer to such inquiries as how much, in what way and if they could be traced so early in the cure, and especially, to what extent are or could be considered (in) the key of the future analysis. [ABSTRACT FROM AUTHOR]

Abstract: In this article we will present our early detection local program of autism and invasive developmental disorders. It is to detect and evaluate children under the age of three, in order to propose proper treatment as quickly as possible. First of all we will present the different aspects of the program working within a network. On one side the collaboration with different structures such as the maternal and infant protection (PMI) and on the other the collaboration with institutions that will specifically take care of these children. The proper evaluation will be then explained and our methods will be further detailed. Secondly, we will share our clinical studies stemmed from our experience and will then consider diagnosis announcement, alliance and therapeutic process. This will then be followed by case studies that will highlight the therapeutic dimension, which already seems to exist in this evaluation phase. [Copyright &y& Elsevier]

Abstract: 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. [Copyright &y& Elsevier]

Abstract: Objectives: Psychoeducation contains the risk of a misunderstanding in the effective experiences of recognition. We want to show that group psychotherapy can be a means to reconcile recommendations in disease prevention aimed by psychoeducative measures, the vivid and lively dimension of experience found in phenomenological attitudes and aspects, turned to the community world of therapeutic mediation. Method: To articulate these various domains, we approach the principles of psychoeducation, the risks which this one can contain and the contributions of clinical phenomenology. Phenomenological method is different from what we call collectively clinical intuition which is always implicitly colored by the typical contexts of meanings of what appears (meanings which have a practical and effective reach for example) and stay, in spite of the critical distance which we can put it, stuffed with various emotional and theoretical predicates muddled between them. The phenomenological attitude aims as much as possible to a suspension of these predicates, that these predicates arise from the common sense of everyday life or that they arise from a detailed specialized knowledge, and this to remove the “coats of sense” which settled on the perception. Results: The group, by its multiple interactions, aims at an optimization of the articulation of the self-relationship with relationship socially adapted to the others. The therapist constantly has to attend to dialectical dynamics which reigns between a certain self-dissolution in the group and a return to oneself from the meshing which build up itself within the group. For certain patients, it is particularly difficult to maintain a just balance between the two moments of identity, the one which is peculiar to oneself and the one which emanates from relations with the others towards which we are normally constantly turned. The interest of this psychotherapeutic work in group is here to offer to each of participants the possibility of holding, with a little more confindence, an existential position within a meshing of social links, that is a capacity to seize oneself as existing among the other beings having themselves an own existence. From there, the subjective capacities of each can be better recognized, what can also give place to adjustment of these capacities with individual aspirations. The active implication of patients, so looked for by psychoeducation, is all the more tangible as we were so able to appeal, by the phenomenological attitude, to what feels immediately and without distance as much in an intimate self-relation as in relationship to the others. Conclusions: Phenomenological attitude allows not to get stuck in imaginary expert skills, in rational projects of organization and other methodical constructions of the science. This attitude is particularly interesting for group psychotherapy which privileges the opening rather than a work of elaboration. The stake is so the authenticity of a real therapeutic alliance based on fine regulations of the global situation of co-presence taking into account the interlacing of the implicit and the explicit in the exchanges which weave with the patients. We privilege a fertile step rather than rigorous observance of a method which would lead only to a systematization against the spirit of phenomenology. The clinical experience shows that this psychotherapeutic method allows in particular a regular attendance of the group, what is one of major ingredients of its efficiency. [Copyright &y& Elsevier]

Abstract: The author addresses three key issues concerning the state of art and the future of consultation-liaison psychiatry. In the context of medico-economic constraints, it is important both to be provided with epidemiological arguments on the prevalence of psychiatric comorbidities in medically ill and their impact on health and sanitary costs, and to seize the opportunity to upgrade consultation-liaison psychiatry, especially through correctly coding of discharge summaries, taking into account such comorbidities, given their impact on hospital receipts. Screening for depressive disorder in medicine remains a priority for consultation-liaison psychiatry. Epidemiology has consistently shown the prognostic value of such symptoms, especially in the cardiovascular field. The relationship between depressive symptoms and cognitive hostility deserve to be better taken into account and can guide the type of follow-up. A growing literature has been devoted to the links between alexithymia, emotional awareness, somatic vulnerability. Several examples are given of the operational nature of these concepts, based on experimental studies, and paths are suggested that open to better understand the links between alexithymia and empathic ability of the patient, but also between empathic ability of the caregiver and therapeutic alliance. These concepts, which refer more to medical psychology than to psychiatric nosography, make the richness of the field of consultation-liaison psychiatry. [Copyright &y& Elsevier]

Abstract: The French Departments of Health and Research have just published the specifications for psychotherapy training. They accredit and guarantee the new – and the last? – stage in the development of psychotherapies, namely that of their “integration.” The latter is based on specific criteria: firstly, methodology: consider all currents, do not create a new system but incorporate methods in the “sequential treatment”: short therapy (about ten sessions), psychotherapy lasting one to two years, long analyses; secondly, epistemology: go beyond (meta-) specific school theories and find the common behaviors, cognitions, social environments, personalities, and unconscious processes; thirdly, clinical: connect methods and specific indications, this is the “pathology-therapy matching” and finally, pragmatism: attain the “nonspecific” factors which constitute 70% of the effectiveness of the therapy: the therapist''s personality, therapeutic alliance, reactions ranging from inter-subjectivity to attachment and transference. The authors propose a 4th degree integration which is not a new system but a new training approach (multidisciplinary team) to create a personal approach for each professional. [Copyright &y& Elsevier]

Abstract: This article consists in a review dealing with three main notions. It first describes the borderline personality disorder. After a short notice on the epidemiology figures and diagnosis criteria, the sub-categories proposed by Gunderson within this disorder are exposed. The etiological hypothesis of the borderline personality disorder, as well as its cognitive psychopathology, according to Beck, are also recalled. Our article then introduces Beck''s cognitive behaviour therapy for borderline patients, and its effectiveness, as assessed by recent international publications. Thirdly, our review is dedicated to the therapeutic alliance. After exposing the concept of therapeutic alliance through Bordin''s pantheoretical approach (relying on the notions of “goals”, “tasks” and “bond”), we examine the therapeutic alliance in borderline patients who follow a cognitive behavioural therapy. The non-compliant attitudes that borderlines tend to adopt are reviewed, as described by international literature, along with Beck''s recommendations to therapists in order to trigger and maintain these patients’ collaboration throughout treatment. Then, a description of the main characteristics of the alliance in borderline patients is proposed, through a short review of publications. [Copyright &y& Elsevier]

Abstract: 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. [Copyright &y& Elsevier]

Abstract: The child is an individual in constant development, dependent on his/her parents with whom he interacts everyday to open out, and in particular, to construct a dependable image of his body for growing up comfortably. Announcement of a disease, real traumatism for the whole family, upsets these exchanges and can often induce psychological difficulties masked by the therapeutic somatic stakes placed at the foreground of concerns of each one: child, parents and doctors. The child''s stakes are construction of a good image of the body (basis of his own) which can be deteriorated by the disease whatever it is (chronic disease, with relapse or vital prognosis engaged). The family''s stakes are the perception of the disease by the parents (distress, culpability, depression) and sibling''s reactions (aggressiveness, identification with the sick child, masked depression, functional troubles). Doctor''s stakes in the chronic disease is to obtain therapeutic alliance of the child and his family to allow the good progress of the treatments. In front of the chronic disease''s reality, it is essential to establish and maintain a multidisciplinary follow up. The child''s psychiatrist role will be to take care of the exchanges and listening among the doctors, the patient and his family are favoured. [Copyright &y& Elsevier]