Follow the testimony of an occupational therapist working in psychosocial rehabilitation in psychiatry. Discover the importance of considering aspects “beyond” the symptom when approaching patients.
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recovery since the 2000s . This concept, in opposition to the medical-centered approach, requires the patient to be the main actor in their care and offers devices that allow them to be more independent.
However, despite this paradigm shift and more multidisciplinary work, we question the place occupied by medical diagnosis and its impact in our current practices . Indeed, it always seems to operate like a rudder, which determines and directs the main areas of care. This has the consequence that caregivers are more in listening and observing the part defined as sick in the patient than in highlighting their resources, both those which are intrinsic to them and those coming from their environment, and more broadly, everything that could make sense in his recovery project.
As an occupational therapist working in a service that offers psychosocial rehabilitation tools, it seems essential to me to recall the importance of not neglecting what lies “beyond” the symptom in the approach to the patient we are dealing with. entrusts. It is not uncommon for me to meet users who have been diagnosed with schizophrenic disorders and who allow themselves to talk about their “traumatic” experience in relation to their symptoms, but also sometimes paradoxically with the diagnosis made. It appears difficult for the patient, even in a space dedicated to this purpose, to express his feelings, his sometimes "out of the ordinary" and often painful experiences, while not forgetting that they could be at the origin of situations of disability.
This was particularly the case for Charlotte, a patient diagnosed with late-onset schizophrenia and for whom it seems that we have missed what really creates an obstacle in her daily life. She allows herself, during an interview conducted according to the methods of the strategic systemic approach, to mention symptoms that may refer to post-traumatic stress syndrome.
Charlotte's case
Presentation of charlotte
Charlotte, aged 49, has benefited from mental health monitoring since 2018 for confusional syndrome with acoustic-verbal hallucinations on a mystical theme. A few months after his first hospitalization, the diagnosis of late-onset schizophrenia was made. For a year, she has been followed in a public mental health establishment and benefits from both medical consultations and care in a Psychosocial Rehabilitation Resource Center. During the admission interview, the patient complained of often being anxious and not feeling sure of herself, just as in society where interacting with others is difficult. After studying Charlotte's request, she is offered therapeutic activities in order to work on self-esteem and self-affirmation, and to exercise her relational skills within a group. The mediator chosen by the patient and the healthcare professional uses various theatrical expression exercises.
The weeks pass and we observe improvements in Charlotte's management of stress. She takes her place within the group and shows herself to be efficient in her relational skills. She seems to flourish in this proposed work, so much so that we think that there will be no continuation of this care which affects her END.
It is during the review of the activity with Charlotte that we realize that, despite her expressed satisfaction, we have not resolved what is obstructing her autonomy. In fact, she always expresses feeling afraid of meeting others, evokes a certain distrust and does not allow herself to consider a professional project. The patient also fears discussing her problems with her psychiatrist, but agrees to talk about them with the caregivers, with whom she says she feels more confident. To follow up on this, we invite the patient to return to her place of care, in order to offer her an interview which best defines what is generating her disability situation today, using the strategic systemic approach . The different meetings and tasks assigned to Charlotte are described below.
Context and intervention methods
It is by relying on the interactional diagram proposed by the strategic systemic approach that we conduct this interview. This guides the therapist's questioning in order to find out from the patient/client how the difficulties are experienced according to the following criteria: relational, emotional, cognitive, behavioral. This diagram therefore allows us to have a global vision of the functioning of the person and their problem within their environment.
The definition of his problem...
It is important to point out that in Charlotte, who appears to be asking for the help we wish to give her, we feel uncomfortable confiding in her and perhaps also have difficulty developing her ideas. His words and answers are often succinct and it is necessary to ask questions in order to help him verbalize. Likewise, his nonverbal expression shows anxiety. It is therefore chosen not to increase negative emotions by only exploiting what it decides to transmit.
Charlotte explains her current problem. She describes not feeling able to enter into relationships with others and therefore not being able to project herself professionally. Charlotte feels torn between what she wants, such as finding a job, and the medical discourse which in this specific case offers her, according to her, disability to put an end to her anxieties. The patient appears doubtful about this alternative to her plans. Charlotte says she is afraid of reaching out to others and above all “afraid that it will start again”. She is invited to further develop what makes this very dominant emotion appear. She discusses what caused her mental health hospitalization and what justified a diagnosis of late-onset schizophrenia in which she did not find herself.
Two years previously, during the funeral ceremony of her cousin, whom she accompanied in the last days before her death, the patient felt something like “an impulse” in her forearm near the coffin. This sensation (which could be translated into mental health as a cenesthetic hallucination) is interpreted by Charlotte as a “sign” sent for her, by her cousin.
Other psycho-physical manifestations and bizarre attitudes then follow which lead the family to be hospitalized at the request of a third party. Indeed, the patient describes herself as absent, even confused, and has difficulty responding to requests from her very worried loved ones.
Under neuroleptic treatment, the patient says she is calmer but...she “ can't stop thinking about it” . These sensations and images come back every day and she says she wants to get them out of her head at all costs. Forgetting becomes a priority. Likewise, she wishes to avoid the places and people her cousin was around, as well as the shamanic rituals which according to her may be at the origin of all these perceptions.
Meeting his vision....
Charlotte has long been attracted to paranormal phenomena and occult sciences. Her cousin practiced shamanism and sometimes invited her to participate in certain rites, by playing the drum, which provoked contradictory feelings in her, both attraction and fear.
As the patient confides, she seems relieved, and we send this impression back to her. Charlotte admits that until now she did not feel able to talk about her beliefs, for fear that they would be misinterpreted or misunderstood by her psychiatrist. If today Charlotte does not go against the prescribed care, she wants to nuance the medical discourse by describing a fragility and a particular sensitivity to all these inexplicable phenomena. She describes herself as torn between the trust she places in “the one who knows”, in this case her psychiatrist, and her beliefs which she says she is not the only one as a person to share and practice. The patient also discusses her attractions for the occult sciences with a priest who is reassuring but encourages her not to pursue these activities which seem to weaken her. Charlotte tells us she wants to put this advice into practice.
In this constructivist approach, we can quote Watzlawick (1988, p.46) who says “the environment as we perceive it is our invention”. From this postulate, our position as therapist will be to join Charlotte in her vision of the world. On the one hand, because what counts is the patient's perception of his reality, whether it is considered outside the norm or not by our society and because this positioning allows the therapist to create this "therapeutic alliance" which is essential for support the person towards lasting and effective change.
On the other hand, this perception can communicate information to the therapist about the means implemented by the patient to try to resolve his problem.
His position
Charlotte currently avoids going out, meeting people and starting new projects as she feels so fragile and incapable, according to her words. Likewise, she refrains from frequenting places that remind her of her cousin, from practicing the occult rituals transmitted by her. She avoids talking about it to her children and those close to her because she does not feel understood and says she wants to protect them from information that could worry them. She appears to be an active participant in the care offered by the hospital, and even very requesting additional therapeutic activities to, according to her, gain more self-confidence.
His emotion
A shock “is like a trauma ”. These are the words of Charlotte who constantly relives and replays this feeling experienced at her cousin's funeral. She describes feelings of anxiety but the object of her fear having been named, we will talk about fear as the main emotion. During our discussions, Charlotte has wide eyes and gives the impression of being oppressed as the object of her fear seems omnipresent.
The exception that confirms the rule
The only times when the patient does not feel invaded by these terrifying images and sensations are when she is with her children and/or her partner, or when she is busy with complex tasks. It is then easier to better understand the need often expressed by Charlotte to participate in more therapeutic activities. Indeed, behind the objectives initially expressed, we hear the wish to be continually moving and to be surrounded in order to put painful ideas and feelings at bay.
The relevant system
In a strategic systemic approach, the relevant system includes the people who can be resources for the patient, as opposed to those who contribute, unconsciously or not, to blocking or perpetuating the problem. The only relevant system mentioned is his mother, present and attentive to his problems, and who accompanies him in his administrative procedures. Charlotte often avoids other members of the family, because the answers given are often advice which ends, paradoxically, by discouraging her by bringing a feeling of guilt. We will be able to question later whether our institution and its care proposals have always been part of its relevant system.
His attempted solution
To the question of “ what bothers you the most Charlotte in your problem?” » The patient replies that it is mainly to constantly think about these images and sensations. Reliving these memories puts the patient at risk of decompensation, in other words of falling back into the state that would have justified hospitalization. Then we ask her what she is doing to remedy this, she answers:
" I try not to think about it "
According to strategic systemic theory, it is when faced with problematic situations with a high emotional component that we can highlight the person's attempt at a solution. There are three main categories of solution attempts: escape, control and interpretation of the situation, according to a “belief” that we seek to confirm (Nardone, 2016).
In Charlotte's case, she first tries to avoid , therefore to flee her thoughts, her feelings for fear of falling into "madness" again.
“It is less the problem itself than the efforts to resolve it that inadvertently perpetuate and exacerbate it. » (Watzlawick, 2010, p.220).
The attempted solution, like a circular causality, which maintains or even worsens a problematic situation. The more Charlotte avoids thinking about these images causing painful and above all frightening sensations, the more they amplify by increasing negative emotions paradoxically making the unwanted object appear.
First prescribed task
The exercise of the worst
The chosen exercise is focused on the patient's problem and consists of consciously imagining the worst, within a framework established in advance by the practitioner. Charlotte should prioritize half an hour in her day and, if possible, be calm. She must imagine everything she fears, what scares her to the point of feeling it physically. Preferably, it programs an alarm clock which sounds the start and end of the task. Once this is finished, she splashes cool water on her face and returns to her daily concerns. As for Charlotte, it will be a question of summoning for half an hour her sensations, her painful feelings that arose during her cousin's funeral.
This exercise illustrates that it is possible to make a symptom disappear by voluntarily evoking it. It's about confronting your fears, your fears in order to weaken them, eliminate them. This task can also be illustrated with the Chinese stratagem “Smother the fire by adding more wood” (Nardone, 2008, p.49).
Return from task implementation
The patient appears relaxed and smiling. We talk about the satisfaction of seeing each other. Indeed, after having prescribed this task with which I felt confident at the time with the patient, I then worried about the possibility that it would put Charlotte in difficulty and generate anxiety in a person diagnosed as psychotic. and for whom stress can increase delusional and/or hallucinatory resurgences.
Th: So tell me how your task went?
Patient: Oh dear, it wasn't easy huh... (laughing) but I did it! (Pride)
Th: Yes, I imagine that what I asked you for an exercise was not simple. Did you do it every day or something?
Patient: Yes every day but sometimes I did it in writing...
Th: And then...?
Patient: Well, it was difficult at the time, but after that, it was less intense.
Th: What then?
Patient: The ideas I'm thinking of... Besides, I have another problem to submit to you.
The idea here is not to transcribe the entire meeting but to focus on what, for me, “worked” and to reflect on the different potential avenues that I could have followed. Charlotte evokes calm and immediately suggests moving on to a problem that seems to be a priority. I am the first surprised by this reaction because, in my opinion, this work would take more time. And above all, I note that the exercises did not increase the patient's anxiety. Collective supervision allows me to understand that for a first task, that of the “trauma novel” would perhaps have been preferable. What is interesting is that when Charlotte transforms the exercise into writing, she takes ownership of the treatment by adapting it herself to her abilities.
However, it is still difficult for me to know, at this moment, if it is the highlighting of a problem which is attenuating, and which allows room for the statement of another problem, appreciated as more important by Charlotte, or if it is a possible disorganization of thought which hinders the hierarchy and prioritization of ideas, as can be observed in psychotic disorders. On the other hand, I have the assurance that the patient trusts me and sees an interest in continuing.
Second problem, new task
Overview of the problem
This time, Charlotte mentions a course on self-esteem offered by Pôle emploi and which will take place very soon. She fears going there because she imagines that the others will know “that she is ill” and “that she no longer knows how to do anything”. A problem often observed in people with psychological disorders: this intimate conviction that “others” know what you are suffering from. This erroneous perception greatly limits their social interactions. Apart from an apprehension that could be described as normal, given this context where she is joining a group of people she does not know, we again observe significant stress where all her skills are called into question and where the reassurance is of no use. As for his companion, he encourages him to “get moving” and find a job. This attitude, although benevolent, does not allow Charlotte to talk to him further because it has the effect of creating a feeling of guilt in her.
To this problem, Charlotte once again describes an attempted solution of the order of avoidance which consists of wanting to think of something else at all costs.
Second prescribed task “the list of negative forecasts”
In this exercise, the person is asked to make a daily list of what they fear the most. Write down all her anxious anticipations, whether they are her ideas, her feelings, what we could say to her or not, do to her or not and which would place her in a very uncomfortable position.
Charlotte must buy a notebook where she will carry out the exercise detailed above; before and during his internship period and this every morning until our next meeting. This exercise is added to the first task in order to consolidate the patient's knowledge. Objective of this task: to put her intrusive thoughts out of her mind and put her anxious anticipations at bay in order to make the most of her internship and the positive corrective experiences that it could bring her.
Return of the implementation of the task by Charlotte
Charlotte appears smiling and seems to have “survived” this internship. She describes her fears and apprehensions but also her successes. I ask Charlotte about her tasks. She first mentions the second task which she ultimately accomplished little: three times over 15 days. She tells me that sometimes she didn't have the time or didn't find it necessary to do the exercise.
TH: And for the first task?
Charlotte: No I didn't need to do it
Th: Oh, why?
Charlotte: I no longer have those ideas in my head.
Th: Is that good news?
Charlotte: Um yes. (Surprise)
Highlighting this success was, in my opinion, important because here the patient is locked into this perception of failure permanently and seems surprised by her progress. Some patients with mental disorders have such difficulties with analysis and introspection, encounter so many obstacles putting them in situations of failure, that it can be difficult for them to appreciate even small victories. Any training process or even what will be her future project (to enter a temp agency), seems to worry the patient because of the same attempts at solutions. The patient is asked to continue this proven exercise and to come back to me only if she feels the need. Charlotte has been very demanding of support in recent years in mental health. Through this action, I wish to place Charlotte in a new position where it is she who evaluates, who experiments with what works or not, thus allowing her a small step towards regaining “power” over herself and her story.
New opportunities in patient recovery
The strategic systemic approach and my meeting with Charlotte made me aware, on the one hand, of the importance of the first contact and the necessary and essential time to address the problem of the person in its entirety, as defended by mental health recovery concept.
“For a quick result you have to take your time”
On the other hand, the strategic systemic approach made me aware of the interest given to the patient's worldview. Charlotte, like many patients we meet, arrives in our services with a diagnosis. For her, he represents an obstacle because he goes against her vision. It therefore appears essential to pay particular attention to the way in which this can be received by the patient and to be interested in the obstacles that it can generate, whether in their daily life but also in their ability to consider future projects.
Charlotte deprives herself for many months of discussing her emotions and the thoughts associated with them, for fear of not agreeing with the advice of the medical profession. The patient explains it by all her projections, plausible or not, in particular on decisions that could be taken with regard to her, whether it be a change of treatment or worse, having to return to the place of hospitalization. For her, this evokes the period of her life when everything changed.
If a diagnosis of late-onset schizophrenia is made, the patient's speech during my interviews reflects symptoms similar to those of post-traumatic stress syndrome. They are linked to the experience of impressive symptoms and their repercussions on her but also on the lives of those close to her. Far be it from me to want to assert a different diagnosis, which does not fall within my field of competence, but to draw attention again to what concerns us and to what must be taken into account if the We want to work in collaboration with the patient, that is to say their vision and their experiences, whether they are realistic or not.
During the interviews, Charlotte took charge of the prescribed tasks without increasing her fear. However, I realize that my medical references, those which allow a diagnosis to be made, sometimes make me doubt the veracity and/or relevance of the comments collected from the patient as well as the choice of my actions. If the WHO defines health as a state of general physical and mental well-being not solely dependent on an absence of pathology, I wonder about the possible negative influence that the diagnosis can still have on the patient today. as much as on the practice of health professionals.
In my work, despite the more humanist visions offered by the new recovery paradigm, I observe that the foundation on which we rely, we caregivers in the psychiatric environment, remains the medical diagnosis. This acts as if it predestined the main areas of care, which makes me think of the Golem theory of Jacobson and Rosenthal in opposition to the Pygmalion effect which consists of conditioning an individual with negative expectations causing a reduction in self-esteem, sense of self-efficacy and performance. In this case, health professionals can unconsciously, with negative or underestimated expectations of the patient's potential or future, condition the patient in such a way that he loses self-confidence and then sees his abilities diminished. Caregivers, under the influence of a classifying doctrine, can in turn influence the proposals and methods of care, not always in accordance with the expectations and real needs of the person. We can see that we are meeting institutional expectations much more often by offering solutions to patients based on what we have at our disposal, whether these are tools or specific know-how.
The patient must normally be informed of why he is consulting. Which may seem obvious, a right. Unlike Charlotte's case, naming one's disorders can sometimes provide relief for the person and their loved ones. Some patients claim that hearing a diagnosis gives them greater insight and insight into where they are going . Their words challenge me. Because how can a diagnosis defined by a global classification, mainly the DSM, determine by itself the orientation of an entire life, omitting individual particularities and the influence of the context, notions favored by systemic approaches.
“There is nothing definitive about the human being...He only knows the incomplete. » (Corcos, 2015, p.203)
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Resources on the systems approach in psychiatry practice
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- Cheat Sheet - Psychiatric care - The fundamentals - Dunod ( https://www.dunod.com )
- From traditional practice to contemporary practice of psychoeducation Érudit ( https://www.erudit.org )
- The Educator and the systemic approach: manual to improve practice - UNESCO ( https://unesdoc.unesco.org/ark:/48223/pf0000137882 )
- For a systemic vision of liaison psychiatry - ScienceDirect ( https://www.sciencedirect.com )
- Center for studies and systemic interventions in methodology and epistemology of care - CEISME ( https://www.ceisme.org )
- French advanced practice nurses, from vision to practice - ScienceDirect ( https://www.sciencedirect.com )
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- Systemic approach in consultation-liaison psychiatry - ScienceDirect ( https://www.sciencedirect.com )
- Systemic therapy and psychiatry - Center for Psychotherapy ( https://www.centredepsychotherapie.fr )
- Systems approach in psychiatry: concepts and practices - Cairn.info ( https://www.cairn.info )
- Systemic theories in psychiatry - Revue de Psychiatrie ( https://www.revue-psychiatrie.fr )
- Clinical applications of the systemic approach in psychiatry - Psychomedia ( https://www.psychomedia.qc.ca )
- The impact of the systemic approach on psychiatric care - Mental Health ( https://www.santementale.fr )
- Responding to psychiatric challenges with the systemic approach - Journal of Psychology ( https://www.journaldepsychologie.fr )
- Systemic psychiatry in practice - Santé Magazine ( https://www.santemagazine.fr )
- Integrative approaches in systemic psychiatry - French Therapy Association ( https://www.aft-therapie.fr )
- Training in systemic therapy for psychiatrists - Academy of Therapy ( https://www.academiedetherapie.fr )
- Systemic interventions in psychiatry - Health Portal ( https://www.portaildelasante.fr )
- The systemic approach and contemporary psychiatric care - Center of Psychiatry ( https://www.centredpsychiatrie.fr )
- The foundations of systemic psychiatry - Presses Universitaires ( https://www.presses-universitaires.fr )
- Evaluation of the systems approach in psychiatry - ScienceDirect ( https://www.sciencedirect.com )