Le tissage de l’alliance thérapeutique en service de soins aigus

Abstract

International audienceAbstract The therapeutic alliance is well-known to be a key factor in the effectiveness of therapy. It is a concept that is widely accepted in the world of research, and is defined by the establishment of an emotional bond that the psychologist forms with their patient, as well as the collaboration between the two partners allowing the definition of relevant goals and tasks recognized as effective to allow the best therapeutic progress for the patient. The studies have highlighted that the nature of the alliance varies according to the care context, the therapeutic approach, and characteristics of the patient and therapist. How is the therapeutic alliance established in an intensive care unit where the life or death nature of the situation intensifies the extreme somatic distress of the patients, disrupts their autonomy and the decision-making process, and marks the therapeutic relationship.The aim of this article is to define the therapeutic alliance in the context of intensive care unit, taking into account the temporality of the emergency, the plurality of actors involved in the care process: patient, close relations and healthcare workers, and the need to maintain the autonomy of a patient who is sometimes psychologically absent from the relationship. The hospitalized patients’s state of health leads to fluctuations of their state of consciousness, on a continuum ranging from coma to wakefulness, passing through phases of confusion. However, essential decisions are taken on their behalf, affecting both their life and their future.Those involved in the patient's care (carers, close relations) provide information to help inform decisions. The trusted support person testifies to what the patient may wish. Exchanges with all those involved in the situation are a prerequisite for the emergence and recognition of the patient's autonomy and subjectivity. A weaving therapeutic alliance is lead through the building of emotional bond of trust with all those involved (patient, family and carers), and by discussing the patient's state of health, experience and therapeutic project with those involved in the intensive care unit, in order to guarantee consent to care.This relational weaving also enables caregivers to gradually gain a more holistic view of their patients, supporting their thinking and the setting up of the best possible therapeutic strategy. Therapeutic objectives and techniques are regularly redefined to ensure they remain relevant as the patient's state of health evolves. This weaving of the alliance engages an ethical conflictuality, in which each person expresses his or her point of view, centered on the patient, and his or her singular experience with him or her, participating in a dynamic of adjustment to a common objective: optimal care for the patient, taking into account his or her opinion as far as possible. The therapeutic alliance that the psychologist establishes in the intensive care setting seems vital to preserving the patient's subjectivity.In this article, the theoretical-clinical thinking is based on anonymized clinical vignettes, preserving patient confidentiality. When vital emergency seems to relegate psychic life to the background, the development of a therapeutic alliance tailored to the characteristics of intensive care is essential to restoring the patient's autonomy and subjectivity.Introduction : L’alliance thérapeutique est reconnue comme un facteur clé d’efficacité thérapeutique. Elle fait l’objet d’une définition consensuelle dans le monde de la recherche, mais celle-ci varie selon les contextes de soin, les patients et leurs thérapeutes. Objectif : Après avoir défini les spécificités de la prise en charge dans un contexte de soin aigu et de réanimation, nous tentons de conceptualiser l’alliance thérapeutique en soin aigu, prenant en compte cette temporalité de l’urgence, la pluralité des acteurs concernés par la prise en charge : patient, proches et équipe soignante, et le maintien de l’autonomie d’un patient parfois absent psychiquement à la relation. Méthode : Nous menons une réflexion théorico-clinique élaborée à partir de vignettes cliniques anonymisées dans cet article. Conclusion : Lorsque l’urgence vitale semble reléguer la vie psychique au second plan, l’élaboration d’une alliance thérapeutique ajustée aux caractéristiques du soin aigu est essentielle pour restaurer le patient dans son autonomie et sa subjectivité