Au-delà et en deçà des techniques cognitives béhaviorales dans le traitement des troubles graves : les facteurs communs

Les thérapies cognitives béhaviorales (TCB) ont vu leur succès s'accroître récemment, en particulier dans le traitement des délires chez les personnes souffrant de troubles mentaux graves. Plusieurs questions demeurent sans réponse, particulièrement quant aux ingrédients actifs dans l'efficacité de ce mode d'intervention. Les auteurs proposent une réflexion intégrative où les facteurs communs comme les variables du client, du thérapeute et de la relation, servent de pistes d'exploration et d'explication.Cognitive behavioral therapies have recently experienced success especially in the treatment of delusions in persons suffering from severe mental disorders. Many questions remain unanswered particularly regarding active ingredients in the efficiency of this mode of intervention. The authors propose an integrative reflection where common factors such as variables of both client and therapist as well as their relationship serve as leads for exploration and explanation.Las terapias cognoscitivas behavioristas (TCB) han visto reciente-mente aumentar su éxito, particularmente en el tratamiento de los deli-rios en las personas que sufren de desordenes mentales graves. Muchas preguntas permanecen sin respuesta, particultarmente en cuato a los in-gredientes activos de la eficacia de este modo de intervention. Los au-tores proponen una reflexion integrativa en donde los factores comunes como las variables del cliente, del terapeuta y de la relaciôn, sirven de pistas de exploraciôn y de explication

Le soutien à l’emploi de type « IPS » pour les personnes souffrant de troubles mentaux graves : une voie d’avenir pour le Québec?

Jusqu'à tout récemment, trois approches principales ont été utilisées aux États-Unis et au Canada pour favoriser l'intégration au travail des personnes souffrant de troubles mentaux graves : formations préparatoires à l'emploi compétitif, emplois non compétitifs proposés comme substituts à l'emploi compétitif et incitatifs et contraintes visant à atténuer les réticences des employeurs potentiels à embaucher des personnes atteintes de troubles mentaux. Le soutien à l'emploi représente une nouvelle approche qui se répand de plus en plus aux États-Unis et au Canada. Le soutien à l'emploi de type «»Individual Placement and Support », ou IPS (Placement et soutien individuels) dont les principes s'appuient sur les résultats de la recherche évaluative, vise le placement aussi rapide que possible dans un emploi régulier choisi en fonction des intérêts et habiletés du client. Il implique une intégration étroite entre les activités de soutien à l'emploi et les activités cliniques. Les études recensées démontrent qu'il est beaucoup plus efficace que les autres approches évaluées quant à l'obtention d'emplois réguliers. Des études québécoises sont nécessaires pour en évaluer l'efficacité ici. Son implantation au Québec soulèverait plusieurs enjeux notamment au niveau de l'organisation des services et des politiques d'emploi et de la sécurité du revenu. Les politiques actuelles facilitent peu l'intégration en milieu de travail régulier.Individual Placement Support (IPS) for people with severe mental disorders : An approach to favor in Québec? Until recently, three major approaches have been used in the USA and Canada to favor employment integration of people with severe mental disorders : training for competitive employment, non-competitive jobs as a substitute to competitive employment and incentives aiming at alleviating hesitation of potential employers to hire people with mental disorders. Supported employment represents a new approach that is increasingly spreading in the USA as well as in Canada. The principles of IPS, based on results of evaluative research, aim at placing individuals as rapidly as possible in regular jobs according to the interests and skills of the client. It implies close integration of both employment support and clinical activities. Studies reviewed show that this approach is more effective than others assessed regarding obtaining regular employment. Studies conducted in Québec are necessary to evaluate its effectiveness here. Its implementation in Québec raises several questions relative to organization of services and employment and income support policies. Current policies do not favor integration in the regular job market.El apoyo de tipo "IPS" para personas que padecen turbios mentales graves: ¿Una vía del futuro para el Québec? Hasta recientemente tres aproximaciones favorecendo la integración al trabajo de personas que padecen de turbios mentales graves han sido utilisadas en Estados Unidos y Canada: formaciones preparatorias al empleo competitivo, empleos non-competitivos como sustitutos al empleo competitivo y obligaciones para atenuar resistencias de empleadores potenciales a contratar personas que padecen turbios mentales. El apoyo al empleo representa una nueva aproximación propagada a través los Estados Unidos y Canada. Los principios del tipo "Individual Placement and Support", o IPS (empleo y apoyo individual) se basan sobre investigaciones cualitativas y con objeto de contratar un empleo regular el más pronto posible. Implica una integración estrecha entre las actividades del apoyo al empleo y las actividades clínicas. La recención de investigaciones demuestra una eficacia más grande de esta aproximación en la busqueda de empleos regulares. Investigaciones quebequenses estan necesarias para evaluar su eficacia aquí. Su establecimiento en Québec plantea varias cuestiones al nivel de la organisación de servicios y politicas de empleo y de seguridad de ingreso. Las politicas actuales facilitan poco la integración en un medio de trabajo regular.Apoio ao emprego de tipo "IPS" para pessoas que sofrem de problemas mentais graves: caminho promissor para o Quebec? Até recentemente, três principais abordagens foram utilizadas nos Estados Unidos e no Canadá para favorecer a integração ao trabalho das pessoas que sofrem de problemas mentais graves: treinamentos preparatórios para o emprego competitivo, empregos não competitivos propostos como substitutos aos empregos competitivos, e medidas incitativas e coercivas que visam atenuar a resistência dos empregadores potenciais em contratar pessoas que sofrem de problemas mentais. O apoio ao emprego representa uma nova abordagem que se difunde cada vez mais nos Estados Unidos e no Canadá. O apoio ao emprego de tipo "Individual Placement and Support", ou IPS (Orientação e Apoio Individual) cujos princípios apóiam-se nos resultados da pesquisa evolutiva, visa a orientação o mais rápido possível para um emprego normal escolhido em função dos interesses e habilidades do paciente. É necessário haver uma integração estreita entre as atividades de apoio ao emprego e as atividades clínicas. Os estudos examinados demonstram que esta abordagem é muito mais eficaz que as outras avaliadas quanto à obtenção de empregos normais. Para avaliar a eficácia desta abordagem aqui no Quebec, serão necessários outros estudos. Sua implantação no Quebec levantaria várias questões, principalmente com respeito à organização dos serviços, das políticas empregatícias e da segurança social. As políticas atuais facilitam pouco a integração ao meio de trabalho normal

Interventions de groupe pour les personnes souffrant de psychose réfractaire

Différentes formes d’interventions de groupe sont offertes aux personnes souffrant de troubles mentaux tel que la schizophrénie. Leur contenu varie considérablement de même que leurs orientations théoriques selon la clientèle visée ainsi que la cible thérapeutique. Cet article propose de décrire trois interventions de groupe : 1) une intervention visant l’amélioration de l’estime de soi, 2) une intervention ciblant la gestion du stress, et 3) une intervention portant sur la diminution de la détresse liée aux symptômes psychotiques par le biais d’une approche cognitive comportementale. Des détails portant sur la mise sur pied de ces trois types de groupe ainsi que leur pertinence théorique et clinique pour les personnes souffrant de psychose réfractaire seront présentés.Various types of group interventions exist for people with severe mental disorders such as schziophrenia. The content and theoretical backgrounds vary according to the therapeutic goals as well as the clientele targeted. This article describes three group interventions : 1) one aiming at improving self-esteem, 2) one aiming at improving competence through stress management, and 3) one aiming at diminushing distress linked to psychotic symptoms with cognitive behavior therapy. Details on how to conduct these three group interventions, as well as their clinical and theoretical relevance for individuals with refractory psychosis will be described.Se ofrecen diferentes formas de intervenciones de grupo a las personas que sufren de trastornos mentales tales como esquizofrenia. Su contenido varía considerablemente, al igual que sus orientaciones teóricas, según la clientela a la que se dirigen, así como su objetivo terapéutico. Este artículo propone describir tres intervenciones de grupo: 1) una intervención que busca la mejora de la estima de sí mismo, 2) una intervención que tiene por objetivo la gestión del estrés, y 3) una intervención que trata la disminución de la angustia relacionada con los síntomas psicóticos por medio de un enfoque cognitivo comportamental. Serán presentados los detalles sobre la puesta en marcha de estos tres tipos de grupo, así como de su pertinecia teórica y clínica para las personas que sufren de psicosis refractaria.Diferentes formas de intervenções em grupo são oferecidas às pessoas que sofrem de problemas mentais, como a esquizofrenia. Seu conteúdo varia consideravelmente, assim como suas orientações teóricas, segundo a clientela visada e o alvo terapêutico. Este artigo propõe descrever três intervenções em grupo: 1) uma intervenção que visa a melhoria da auto-estima, 2) uma intervenção focalizada na gestão do estresse, e 3) uma intervenção que trata sobre a diminuição da depressão ligada aos sintomas psicóticos, através de uma abordagem cognitiva comportamental. São apresentados detalhes sobre a criação destes três tipos de grupo, assim como sua pertinência teórica e clínica para pessoas que sofrem de psicose refratária

Cognitive behaviour therapy for schizophrenia

Schizophrenia is one of the major and potentially severe mental illnesses. Even with best practices, there are limitations to the effectiveness of treatments that include medications for this disorder. Relapse rates are high and often those with the illness remain symptomatic and functionally impaired. All the evidence suggests that individuals with schizophrenia do best with a combination of pharmacological and psychosocial intervention. One psychosocial treatment that has received much attention is cognitive behaviour therapy (CBT). This brief review will address what we know about the use and effectiveness of CBT at all phases of schizophrenia and its strengths, weaknesses and its future

La schizophrénie dissociative existe-t-elle ?

Cet article examine le chevauchement important qui existe au niveau phénoménologique, entre les symptômes dissociatifs et psychotiques. De plus, l’étiologie traumatique, reconnue dans les troubles dissociatifs, semble de plus en plus considérée dans les cas de psychoses. Ces similitudes créent une confusion dans les milieux cliniques avec des répercussions importantes pour les personnes souffrant de ces troubles. En effet, les difficultés rencontrées lors du diagnostic différentiel peuvent résulter soit en un mauvais diagnostic, soit en une comorbidité indétectée. Certains auteurs vont plus loin et postulent qu’il existe un sous-type de schizophrénie dont la dissociation est sous-jacente à l’expression des symptômes psychotiques.On a phenomenological level, there’s an important overlap between dissociative and psychotic symptoms. Furthermore, traumatic etiology, recognized in dissociative disorders, is also increasingly considered in psychosis. These similarities create confusion in clinical settings with important repercussions for individuals suffering from these disorders. Indeed, difficulties encountered in differential diagnoses could result in an erroneous diagnosis or in an undetected comorbidity. Some authors are going further in suggesting that there is a sub-type of schizophrenia having dissociation behind the expression of psychotic symptoms.A nivel fenomenológico existe una imbricación importante entre los síntomas disociativos y psicóticos. Además, la etiología traumática reconocida en los trastornos disociativos parece ser cada vez más considerada en los casos de psicosis. Estas similitudes crean una confusión en los medios clínicos con repercusiones importantes para las personas que sufren de estos trastornos. De hecho, las dificultades encontradas durante el diagnóstico diferencial pueden resultar ya sea en un diagnóstico incorrecto o en una comorbilidad no detectada. Algunos autores van más allá y proponen que existe un subtipo de esquizofrenia con disociación subyacente a la expresión de los síntomas psicóticos.Ao nível fenomenológico, existe uma sobreposição importante entre os sintomas dissociativos e psicóticos. Além disto, a etiologia traumática, reconhecida nos transtornos dissociativos, parece ser cada vez mais considerada nos casos de psicoses. Estas semelhanças criam uma confusão nos meios clínicos com repercussões importantes para as pessoas que sofrem destes transtornos. De fato, as dificuldades encontradas durante o diagnóstico diferencial podem resultar em um mau diagnóstico, ou em uma comorbidade não detectada. Alguns autores vão mais além e propõem a existência de um sub-tipo de esquizofrenia que tenha a dissociação sub-jacente à expressão dos sintomas psicóticos

Measurement invariance of the Marijuana Motives Measure among men and women using Stop Cannabis App

Motives to use cannabis play a central role in the development and maintenance of problematic cannabis use and previous studies stressed sex-related differences on motives to use cannabis. However, motives cannot be validly compared in men and women without first establishing the measurement invariance across sex. Therefore, the aim of the study is to (1) examine for the first time the measurement and structural invariance of the Marijuana Motives Measure (MMM) across sex, and (2) to investigate the motives for cannabis use that best explain problematic use. 2951 (41.7% women) users of the "Stop cannabis" smartphone app of which 99.8% reported having used cannabis in the last three months completed an online MMM and ASSIST to assess the severity of their problematic cannabis use. Multigroup confirmatory factor analyses supported measurement invariance across sex, whereas structural invariance was not confirmed. Indeed, group comparisons indicated that women reported greater coping motives then men whereas men showed greater social motives than women. A multiple linear regression analysis showed that only coping and conformity motives were significantly associated with greater problematic cannabis use, whereas neither sex nor the sex by motives interactions were significantly related to problematic cannabis use. The MMM appears to function comparably across men and women. Therefore, sex-related comparisons on the questionnaire can be considered valid. Coping and conformity motives may play a central role part in the development of marijuana use problems which may hold implications for intervention development and public policy

Evaluating preferences for online psychological interventions to decrease cannabis use in young adults with psychosis : an observational study

Innovative technology-based solutions have the potential to improve access to clinically proven interventions for cannabis use disorder (CUD) in individuals with first episode psychosis (FEP). High patient engagement with app-based interventions is critical for achieving optimal outcomes. 104 individuals 18 to 35 years old with FEP and CUD from three Canadian provinces completed an electronic survey to evaluate preferences for online psychological intervention intensity, participation autonomy, feedback related to cannabis use, and technology platforms and app functionalities. The development of the questionnaire was informed by a qualitative study that included patients and clinicians. We used Best-Worst Scaling (BWS) and item ranking methodologies to measure preferences. Conditional logistic regression models for BWS data revealed high preferences for moderate intervention intensity (e.g., modules with a length of 15 min) and treatment autonomy that included preferences for using technology-based interventions and receiving feedback related to cannabis use once a week. Luce regression models for rank items revealed high preferences for smartphone-based apps, video intervention components, and having access to synchronous communications with clinicians and gamification elements. Results informed the development of iCanChange (iCC), a smartphone-based intervention for the treatment of CUD in individuals with FEP that is undergoing clinical testing

Reducing cannabis use in young adults with psychosis using iCanChange, a mobile health app : protocol for a pilot randomized controlled trial (ReCAP-iCC)

Background: Cannabis use is the most prevalent among adolescents and young adults; frequent consumption is associated with cannabis use disorder (CUD) and psychosis, with a high prevalence (up to 50%) of CUD in individuals with first-episode psychosis (FEP). Early Intervention Services (EIS) for psychosis include face-to-face psychosocial interventions for CUD, because reducing or discontinuing cannabis use improves clinical and health care service use outcomes. However, multiple barriers (eg, staff availability and limited access to treatment) can hinder the implementation of these interventions. Mobile health (mHealth) interventions may help circumvent some of these barriers; however, to date, no study has evaluated the effects of mHealth psychological interventions for CUD in individuals with FEP. Objective: This study describes the protocol for a pilot randomized controlled trial using a novel mHealth psychological intervention (iCanChange [iCC]) to address CUD in young adults with FEP. iCC was developed based on clinical evidence showing that in individuals without psychosis, integrating the principles of cognitive behavioral therapy, motivational interviewing, and behavioral self-management approaches are effective in improving cannabis use–related outcomes. Methods: Consenting individuals (n=100) meeting the inclusion criteria (eg, aged 18-35 years with FEP and CUD) will be randomly allocated in a 1:1 ratio to the intervention (iCC+modified EIS) or control (EIS) group. The iCC is fully automatized and contains 21 modules that are completed over a 12-week period and 3 booster modules available during the 3-month follow-up period. Validated self-report measures will be taken via in-person assessments at baseline and at 6, 12 (end point), and 24 weeks (end of trial); iCC use data will be collected directly from the mobile app. Primary outcomes are intervention completion and trial retention rates, and secondary outcomes are cannabis use quantity, participant satisfaction, app use, and trial recruiting parameters. Exploratory outcomes include severity of psychotic symptoms and CUD severity. For primary outcomes, we will use the chi-square test using data collected at week 12. We will consider participation in iCC acceptable if ≥50% of the participants complete at least 11 out of 21 intervention modules and the trial feasible if attrition does not reach 50%. We will use analysis of covariance and mixed-effects models for secondary outcomes and generalized estimating equation multivariable analyses for exploratory outcomes. Results: Recruitment began in July 2022, and data collection is anticipated to be completed in July 2024. The main results are expected to be submitted for publication in 2024. We will engage patient partners and other stakeholders in creating a multifaceted knowledge translation plan to reach a diverse audience. Conclusions: If feasible, this study will provide essential data for a larger-scale efficacy trial of iCC on cannabis use outcomes in individuals with FEP and CUD