Traitement multimodal de l’agressivité et de la violence chez des personnes souffrant de psychose

Integrating Jungian and Self-Psychological Perspectives Within Cognitive-Behavior Therapy for a Young Man With a Fixed Religious Delusion

Although cognitive-behavior therapy (CBT) can be effective in reducing delusional thinking in schizophrenia, many patients are considered poor candidates, typically because of a lack of distress from the delusion and resistance or low motivation to challenge its validity. Recent developments in CBT for schizophrenia, however, stress the need to move from a sole focus on challenging beliefs toward a person-based model in which recognition of the vulnerability of the self guides treatment and the content of therapy is perceived as personally meaningful by the patient. This article demonstrates how the Jungian technique of archetypal amplification was modified and used within the structure of CBT treatment of a young man with schizophrenia with a religious delusion who refused to engage in standard CBT. His case demonstrates that schizophrenia patients who initially refuse to question the validity of their delusional beliefs can nevertheless be successfully engaged in CBT when the focus promotes alternative understandings of the self and preserves self-esteem.

The experience of seclusion and restraint in psychiatric settings: perspectives of patients

Many studies report that the use of seclusion and restraint (SR) is experienced negatively by patients who experience feelings of shame, helplessness, and humiliation, and may relive previous trauma events. Since 2000, in Québec, exceptional measures like SR have been framed by a protocol. This protocol provides health care teams with guidelines for relieving, containing, and reducing the suffering caused by SR. We have no knowledge, however, about the views of patients regarding application of the protocol. This study aims to understand the perception of patients regarding application of the SR protocol. For this purpose, a questionnaire was presented to patients (n = 50) who experienced an episode of SR in a psychiatric hospital in Canada. Results show that patients had a nuanced perception of SR: Some felt that SR was a helpful measure, while others felt that SR was not a helpful measure. Patients tended to agree with statements related to the comfort and safety of seclusion rooms and the meeting of their physical needs. Regarding support, they suggested relational, drug, and environmental interventions to prevent seclusion. Finally, nearly all patients perceived that the health care team did not follow-up with the patients after the experience; such follow-up is essential for reconstructing a sometimes confusing event.

[Psychiatric medication as restraint: between autonomy and protection, is there place for a legal framework?]

The use of chemical restraint has been regulated for the past ten years in Quebec. However, clinical, ethical and legal issues, sometimes contradictory, have not really been considered during the legislative process leading to consolidation in its current form. The author supports that, because of the absence of consent and the effects of medication, a specific legal framework to the use of medication is necessary in a context of unplanned intervention to protect both patients and medical staff. This framework would prescribe good practice, take into account the non-medical aspects of consent to care and formalize the practice as an exception to the rule. In addition, the symbolism of law, through which social solidarity can be expressed, must not be underestimated.

Prevalence and correlates of seclusion with or without restraint in a Canadian psychiatric hospital: a 2-year retrospective audit

Seclusion with or without restraint is a measure used to manage patients with challenging behaviours. Although controversial, the intervention remains poorly documented, especially in Canadian psychiatric hospitals. The purpose of this study is to assess the prevalence of the measure and identify any correlated demographic characteristics and psychiatric disorders. Episodes of seclusion with or without restraint were extracted from a computerized, hospital-based system introduced specifically to track such interventions. Of 2721 patients hospitalized during that time, 23.2% (n = 632) were secluded with or without restraint, and 17.5% (n = 476) were secluded with restraint. Younger age, schizophrenia or other psychosis, bipolar and personality disorder, and longer stay in hospital are predictors of an episode of seclusion with or without restraint. Younger age, bipolar and personality disorders and a longer stay in hospital are predictors of an episode of seclusion with restraint. For patients who spent longer in seclusion and under restraint, there is a positive association with longer stay in hospital. In this inpatient psychiatric facility, seclusion with or without restraint thus appears to be common. More research is warranted to better identify the principal factors associated with seclusion and restraint and help reduce resort to these measures.

[Dangerous states and mental health disorders: perceptions and reality]

Image of Madness was always strongly linked with the notion of "dangerousness", provoking fear and social exclusion, despite the evolution of psychiatric practices and organisation, and the emphasis on user's rights respect. Mediatization and politicization of this issue through news item combining crime and mental illness, reinforce and spread out this perception. This paper presents a review of the litterature on social perceptions associating "dangerousness", "Insanity" and "mental illness", available data about the link between "dangerous states" and "psychiatric disorders", as well as the notion of "dangerousness" and the assessment of "dangerous state" of people suffering or not from psychiatric disorders. MAPPING OF SOCIAL REPRESENTATIONS: The French Survey "Mental Health in General Population: Images and Realities (MHGP)" was carried out between 1999 and 2003, on a representative sample of 36.000 individuals over 18 years old. It aims at describing the social representations of the population about "insanity/insane" and "mental illness/mentally ill". The results show that about 75% of the people interviewed link "insanity" or "mental illness" with "criminal or violent acts". Young people and those with a high level of education more frequently categorize violent and dangerous behaviours in the field of Mental illness rather than in that of madness. CORRELATION BETWEEN DANGEROUS STATE AND PSYCHIATRIC DISORDERS: in the scientific literature, all experts reject the hypothesis of a direct link between violence and mental disorder. Besides, 2 tendencies appear in their conclusions: on one hand, some studies establish a significative link between violence and severe mental illness, compared with the general population. On the other hand, results show that 87 to 97% of des aggressors are not mentally ills. Therefore, the absence of scientific consensus feeds the confusion and reinforce the link of causality between psychiatric disorders and violence. OFFICIAL FIGURES BY THE MINISTRY OF JUSTICE: according to the French Ministry of Justice, there is a lack of significative data in general population, that would allow the accurate evaluation of the proportion of authors of crimes and offences presenting a "dangerous state", either of criminological order or related to a psychiatric disorder. FROM "DANGEROUSNESS" TO "DANGEROUS STATE": the vagueness of the notion of "dangerousness" aggravates the confusion and reinforce the negative social representations attached to subjects labelled as "mentally ills". A way to alleviate this stigmatisation would be to stop using the word "dangerous", and rather use those of "dangerous states". Assessment of dangerous states is complex and needs to take into account several heterogeneous factors (circumstances of acting, social and family environment...). Besides, it is not a linear process for a given individual. Those risk factors of "dangerous state" lead to the construction of evaluation or prediction scales, which limits lay in the biaises of over or under predictive value. The overestimation of dangerousness is harmful, not only to individuals wrongly considered as "dangerous", but also to the society which, driven by safety concerns, agrees on the implementation of inaccurate measures. A FEW TRACKS FOR REMEDIATION: the representations linking "mental illness" and "dangerousness" are the major vectors of stigma, and deeply anchored in the collective popular imagination. They are shared by all population categories, with no distinction of age, gender, professional status or level of education. To overcome those prejudices, one has to carefully study their basis, their criteria, document them with statistical data, look for consistency and scientific rigour, in the terminology as well as in the methodology. Moreover, one has to encourage exchanges about this topic, between users, relatives, carers, local elected, politicians, media and health professional.

Nursing practices recorded in reports of episodes of seclusion

The purpose of this study is to describe the nursing practices recorded in reports of patient episodes of seclusion, with or without restraints, in a specialized psychiatric facility in Quebec. The reports for all adult patients secluded (n = 4863) in a psychiatric unit between April 1, 2007 and March 31, 2009, were examined. Descriptive analyses were performed. The main reasons for seclusion were agitation, disorganization, and aggressive behaviour. The alternative methods that were attempted included stimulus reduction, extra medication, and working with the patient to find a solution. Few families were notified about their relation's seclusion. More hours of seclusion were reported in the evening and at night. Our results are comparable to those obtained by other investigators. Some of the variables have not been the subject of much research: for example, health conditions during seclusion with or without restraint and partnerships with family members. Our findings also suggest that, in their analyses, studies should differentiate between cognitive-impairment and adult-psychiatry units as well as long-term seclusion and short-term seclusion. The information reported by the nurse makes no distinction between short-stay and long-stay adult psychiatric units. Only one psychiatric facility was investigated in this study, precluding generalization.

The nursing decision making process in seclusion episodes in a psychiatric facility

This study explores and describes nursing interventions performed during episodes of seclusion with or without restraint in a psychiatric facility and examines the relationship between the interventions' local protocols and best-practice guidelines. Twenty-four nurses working in a psychiatric facility were interviewed about the nursing interventions they performed before, during, and after an episode of seclusion with or without using restraint. Analysis of the data reveals that the interventions meet quality standards. However, nursing practice would be further refined by conducting post-event reviews, especially by discussing how a client's aggressive behaviour is to be understood.

Factors influencing decisions on seclusion and restraint

Seclusion with or without restraint is a measure for managing aggressive or agitated clients and promoting site security, particularly in an emergency psychiatric setting. The decision to control a potentially dangerous person's behaviour by removal or seclusion seems ethically justifiable in such a setting. However, although the decisions on these restrictive measures are based on rational needs, they are also influenced by the healthcare team's perceptions of the client and by the characteristics of the team and the environment. The purpose of this paper is to set out and categorize the factors in play in aggression- and agitation-management situations as perceived by the healthcare teams, particularly the nurses. The first part of the paper deals briefly with the settings in which control measures are applied in a province in eastern Canada and the effect of such measures on patients and healthcare teams. The second part identifies the factors involved in the management of agitation and aggression behaviour. The final part discusses the current spin-offs from this knowledge as well as promising paths for further research on the factors involved. The ultimate objective is to reduce recourse to coercive measures and enhance professional practices.