Les relations thérapeutiques en psychiatrie hospitalière

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.