Suicide et bipolarité : les approches cognitives et comportementales

Abstract

Les thérapies comportementales et cognitives sont proposées aujourd’hui aux patients bipolaires sous forme de programmes spécifiques dont le but est d’améliorer la prise en charge des fluctuations de l’humeur, particulièrement les états dépressifs ou les dépressions et de diminuer le risque suicidaire. Nous proposons une description détaillée de l’approche des idéations suicidaires du programme de Newman et de la comparer à celle de Basco et Rush. La démarche de Newman se distingue par le contrat de sécurité, par la recherche d’une image positive du futur contre le suicide ainsi que la procrastination du suicide ; celle de Basco se caractérise par la résolution de problème en trois étapes : ralentir, se concentrer et structurer qui est aussi adoptée dans la manie. Behavioral and cognitive therapies are now provided to bipolar patients in specific programs aimed at improving the management of mood swings, especially depressive states or depression, and reducing suicidal risk. A detailed description of Newman's approach on bipolar disorders in individual behavioral and cognitive therapy is presented and then compared with Basco and Rush's approach. When dealing with patients expressing suicidal thoughts, Newman proposes discussing arguments against suicide, and establishing “anti-suicide” contracts that involve therapeutic alternatives such as calling the therapist, the emergency room, a colleague or certain people in the health system and obtaining the patient's commitment to live, even if he has difficulties respecting all of the contract's details. The contract does not replace the usual methods of monitoring suicidal risk and treatment response, it simply is complementary and a way to organize a response to a crisis situation. Suicidal patients often express negative thoughts validating suicide as a viable option. The therapist's role is to help the patient explore these thoughts with an aim to restructuring them, as well as to define the pros and cons of suicide. Indeed, many suicidal patients believe that the future will only present problems and that the only way of escaping it is death; thus they are primarily focused on the apparent benefits of suicide. Few patients consider the disadvantages of a premature death, the advantages of living, and the consequences of suicide on their relatives. The therapist draws the patient's attention to these forgotten elements and helps him/her imagine a better future; this procedure is sometimes known as “positive image of the future”. One way for patients to find a renewed interest in life is to participate in satisfying and enjoyable activities. A new method of remaining active against suicide is to “temporize”; patients perform unfinished tasks one after the other in order to reflect on their commitments to life. It can be useful to teach patients problem solving techniques. Since they tend to manifest negative behavior, it is useful to teach them “damage control” principles and to optimize their social support. Basco and Rush suggest a problem solving technique where they ask the patient to resolve the situation as if it was happening to someone else. They also suggest another way to combat suicidal thoughts: focusing on reasons to live. The strength of this exercise lies in the patient's ability to leave behind thoughts of absolute despair and in considering that he has to live longer to see things improve. Basco and Rush stress the importance of reinstating relationships and to avoid isolation. As with obsessions, Basco and Rush suggest three steps to manage depression: relaxation exercises, reducing internal and external stimuli; focusing by establishing a priority list and structuring by reducing your mental list, by solving problems, by making decisions, by discussing the pros and cons and getting feedback from others; and finally, using the 24-hour rule (waiting to put a decision into action). Newman's approach is characterized the use of a safety contract, attributing a positive image to the future, as well as delaying tactics. Basco and Rush's approach is characterized by problem solving in three stages that they have also used in the treatment of OCD.