La psychothérapie assistée par la MDMA dans la prise en charge du syndrome de stress post-traumatique

Posttraumatic stress disorder (PTSD) is estimated to remain chronic and severe for 25–50% of patients despite psychotherapeutic treatment. Part of the reasons is that patients with PTSD can have difficulties in establishing a good therapeutical alliance with the therapist. Moreover, they often fail to re-think the content of the trauma without being overwhelmed by negative emotions and tend to rely on avoidance strategies and/or to abandon the therapy. MDMA (“ecstasy”) is a drug classified as an entactogen (en “within”, tactus “touch”, and gen “produce”), an amphetamine with psychedelic properties that possesses psychopharmacological properties to overcome these issues. Indeed, MDMA triggers the release of oxytocin, which favors the establishment of interpersonal relationship based on kindness and trust. Moreover, MDMA diminishes the activity of the amygdale, allowing patients to work on challenging memories with less fear and anxiety. Finally, MDMA may also provide access to meaningful spiritual experiences, release of tensions and a sense of healing on a non-verbal level that are not completely understood. But are viewed as important by patients. Today, there is no evidence that the use of MDMA in a clinical setting has bad neurologic, psychological or cognitive consequences. Results of phase II trials in the United States and Europe confirm that MDMA favors psychotherapy's outcome without severe adverse effects. Phase III trials are underway. The Multidisciplinary Association for Psychedelic Studies (MAPS) has published online a method proposal and trains therapists in MDMA-assisted psychotherapy.ConclusionFood and Drug Administration (FDA) and European Medicines Agency (EMA) could approve this therapeutic tool in the coming years.     

Fonctionnements et dysfonctionnements des psychothérapies : synthèse de la littérature et présentation de deux méthodologies associées aux meilleurs résultats

IntroductionPsychological difficulties are part of higher stakes health issues. What are the real effects and the difficulties to generate results of psychotherapies?Literature resultsPsychotherapy is efficient for multiple psychological disorders, as well in controlled as in naturalistic studies, and participate in reduction of health expenditure. However, all patients do not get real benefits from care, patients can deteriorate or drop-out treatment, and persistent side effects can occur; clinicians overestimate their efficiency and their performances decline during their career. Two promising methodologies seems to be associated with better outcomes: Routine Outcome Monitoring (ROM) and a specific form of training clinician expertise named “Deliberate Practice”.DiscussionUsing client feedback allows to implement ROM and “Deliberate Practice” in routine care.ConclusionImplementation of Routine Outcome Monitoring should be encouraged in French Speaking countries to produce evidence-informed practice for the delivering, the improvement and the payment for psychotherapy expenditure.     

The catharsis hypothesis,aggressive drive,and the reduction of aggression

The import of the concept of aggressive drive for the construct of catharsis, particularly the trend toward alternatives to drive concepts, is considered. Three conceptions of catharsis are distinguished—the Dramatic model, the Clinical model and the Experimental model. The Dramatic and Clinical models are seen to focus on affective engagement and change, while differing in the vicarious nature of the cathartic experience, in the degree of cognitive representation entailed, and in the nature of the interpersonal context. The Experimental model is seen to be addressed to the more general problem of aggression reduction through aggressive acts. The Dramatic and Clinical models of catharsis are viewed as more specific and germane, and the hypothesis is proposed that catharsis obtains in the case of inhibited rather than persistent or unresolved affect.     

Contrasting Social Climates of Small Peer-Run Versus a Larger Staff-Run Substance Abuse Recovery Setting

This study compared the social climate of peer‐run homes for recovering substance abusers called Oxford House (OH) to that of a staffed residential therapeutic community (TC). Residents of OHs (N = 70) and the TC (N = 62) completed the Community Oriented Programs Environment Scales. OHs structurally differ on two primary dimensions from TCs in that they tend to be smaller and are self‐run rather than professionally run. Findings indicated significantly higher Involvement, Support, Practical Orientation, Spontaneity, Autonomy, Order and Organization, and Program Clarity scores among the OH compared to TC residents. Additional analyses found the OH condition was higher Support, Personal Problem Orientation, and Order and Organization scores among women compared to men residents. These results suggested that these smaller OH self‐run environments created a more involving and supportive social milieu than a larger staff‐run TC. These findings are interpreted within Moos' ( 2007 ) four theoretical ingredients (i.e., social control, social learning, behavioral economics, and stress and coping), which help account for effective substance abuse treatment environments.     

Jardin thérapeutique,outil de prévention du burnout

The aim of this research was to study the effect of the presence of a garden in a hospital care sector on caregiver burnout. Eighty-eight nurses and caregivers from 9 care sectors answered a questionnaire constructed from the theories and scales of Karasek and Theorell. Three types of services were compared (cognitive behavioral unit, palliative care, post-acute and rehabilitation care) with a garden adapted for therapeutic activities versus with a regular garden versus with no garden. The main result was a lesser incidence of burnout in care services with a garden that those without a garden, irrespective of the type of care service, along with an amplification of the benefit with specially-designed gardens. The feeling of strength, both physical and psychological, was less present when the care services did not have a garden. A trend toward an increase in musculoskeletal disorders in services with a therapeutic garden versus no garden was observed. Upon analyzing the results, the authors recommend particular attention in the designing of hospital gardens in order to facilitate the ergonomics of nursing work. The overall results advocate the use of the garden as a systemic structure conducive to work interactions in a specially-designed area.     

L’évaluation thérapeutique : description de quatre modèles

Since its development, therapeutic assessment (TA) has been used in many different settings and adapted accordingly. There are four different TA models: adult, couple, child and adolescent. This article presents the steps of each model and addresses the specific similarities and differences between them.     

The symbolism of the story of Lot and his wife: the function of the 'present relationship' and non-interpretative aspects of the therapeutic relationship in facilitating change

Abstract The treatment of an adolescent patient preoccupied with thoughts about committing suicide is presented, as a vehicle for considering the significance of the 'present relationship' within the totality of the therapeutic relationship in bringing about change. The question of how the present relationship operates alongside the transference relationship is raised. It is argued that there needs to be more attention to and discussion of the therapeutic actions and re-enactments that take place within therapy which, while they may be viewed at times as unorthodox, may nevertheless be beneficial. This in turn can then lead to developments in technical and theoretical thinking based on clinical experience.     

Drawing as a means of communication at the initial interview with children with cancer

Cancer is always associated with distress and fear. In working with children who have cancer, a trusting relationship and meaningful dialogue often cannot be established by talking on its own. Drawings may offer an opportunity for children to express their feelings without giving up resistance completely. This paper summarizes the aims of the first interview with an ill child, one of its main purposes being the evaluation of the children's and their family's resources to cope with the strains of the illness. The meaning of drawings in this process is discussed in two case reports.     

Risk and Trust in Public Health: A Cautionary Tale

The leading ethical position on placebo-controlled clinical trials is that whenever proven effective treatment exists for a given condition, it is unethical to test a new treatment for that condition against placebo. Invoking the principle of clinical equipoise, opponents of placebo-controlled trials in the face of proven effective treatment argue that they (1) violate the therapeutic obligation of physicians to offer optimal medical care and (2) lack both scientific and clinical merit. We contend that both of these arguments are mistaken. Clinical equipoise provides erroneous ethical guidance in the case of placebo-controlled trials, because it ignores the ethically relevant distinction between clinical trials and treatment in the context of clinical medicine and the methodological limitations of active-controlled trials. Placebo controls are ethically justifiable when they are supported by sound methodological considerations and their use does not expose research participants to excessive risks of harm.     

Working alliance as a predictor of change in depression during blended cognitive behaviour therapy

Blended Cognitive Behaviour Therapy (bCBT) is a new form of treatment, mixing internet-based modules and face-to-face therapist sessions. How participants rate the therapeutic alliance in bCBT has not yet been thoroughly explored, and neither is it clear whether therapist- and patient-rated alliances are predictors of change in depression during treatment. Depression and alliance ratings from 73 participants in a treatment study on bCBT (part of the E-COMPARED project) were analysed using growth curve models. Alliance, as rated by both patients and therapists, was high. The therapist-rated working alliance was predictive of subsequent changes in depression scores during treatment, whereas the patient-rated alliance was not. A therapeutic alliance can be established in bCBT. The role of the therapist-rated alliance seems to be of particular importance and should be carefully considered when collecting data in future studies on bCBT.