Hôpital de jour de psychiatrie orienté réhabilitation psychosociale : quelle place pour la psychanalyse ?

Objectives

This paper relates how relevant can be a psychoanalytic care intermixed within a psychosocial rehabilitation approach in a psychiatric day hospital. The psychiatric day hospital of the 15th district of Paris at GHU Paris Psychiatrie & Neurosciences (HDJ) specialized in the care of adult patients, primarily those suffering from schizophrenia and other severe mental disorders. Established in the 1990s, the HDJ was initially influenced by psychoanalytic theories, particularly those of Jacques Lacan. However, in 2015, the HDJ underwent a significant evolution due to the transformation of psychiatric services in the 15th district. This led to a shift towards a psychosocial rehabilitation model focused on recovery and social-professional reintegration. The HDJ redefined its identity as a transitional space for recovery, emphasizing the importance of rehabilitation and reintegration into society. The new care model introduced a structured approach to treatment, focusing on the development of individualized projects and the opportunity of professional reintegration from the outset of care. The concept for care is based on cognitive remediation, cognitive behavior therapy and psychoanalytical therapy.

Methods

Psychosocial rehabilitation is defined as a set of processes aimed at helping individuals with mental disorders achieving a satisfying quality of life in accordance to their expectations. It is based on the belief that every person can progress towards a personalized project for life. The rehabilitation process encompasses clinical (symptoms, treatments), functional (cognitive abilities, relationships, autonomy), and social (housing, budget management, employment) dimensions. The HDJ assumed these principles and incorporated them into a model for care, based on the clinical experience of the multidisciplinary team. This team included clinical stakeholders with psychoanalytic orientations. Practically, after an initial assessment, the treatment pathway is now organized into three phases: 1. Stabilization and clinical consolidation: The first period consists in a whole effort to reach clinical remission and consolidation. The focus is on defining treatment goals and directing patients to workshops that address their specific needs. 2. Functional Rehabilitation: Once acute crises have been overcome, this phase allows for the evaluation of residual difficulties and the identification of patient's strengths. 3. Rehabilitation and Reintegration: The final phase focuses on personalized cognitive remediation programs aimed at restoring cognitive deficits. Social workers facilitate connections with rehabilitation, social inclusion and employment services to support patient's professional wishes. The HDJ emphasizes the importance of psychoanalysis in understanding the relational dynamics of patients. Psychoanalytic principles help staff recognize and respond to patient's unconscious relational patterns, enhancing the therapeutic relationship. This approach fosters a supportive environment where patients can express their personal experience and feelings, two essential dimensions for their recovery.

Results

This text shows how to bridge the gap between different models for care which could be intuitively not really compatible. Cognitive remediation and cognitive behavioral therapy provide tools that aims to prepare the patient to be ready for employment issues. The integration of psychoanalysis allows for a deep comprehension of each patient's unique journey, acknowledging that recovery is not merely based on symptom management but also on a personal transformation and on an identity reconstruction. The commitment of this HDJ to individualized care has led to significant improvements in professional reintegration rates, increasing from 24% to 70%, while also reducing the average length of stay from 69 to 17 months with maintain of rehabilitation project two years after the end of hospitalization in the HDJ. In this manuscript, two clinical cases illustrate this way to exert integrative clinical practice and feature the personalization of the course of patients for rehabilitation and recovery.

Conclusion

This psychiatric day hospital oriented toward integrative models for care and recovery exemplifies a progressive model of psychiatric care that combines psychosocial rehabilitation with psychoanalytic insights. This dual approach not only addresses the clinical needs of patients but also supports their personal transformation and reintegration into the social community. These approaches complement each other, promoting patient's empowerment and self-determination. While rehabilitation provides a frame for care, psychoanalysis ensures that care also addresses individual subjectivity and unconscious issues, enhancing the overall effectiveness of the treatment.