Thérapie cognitive basée sur le concept de rétablissement pour la schizophrénie : un cas clinique

Si l’on sait depuis de nombreuses années qu’un travail axé sur le rétablissement s’avère primordial dans la prise en soin des patients souffrant de schizophrénie, il n’est pas toujours évident d’en traduire les principes dans nos interventions. La thérapie cognitive orientée sur le rétablissement, développée par l’équipe d’Aaron T. Beck, est une approche particulièrement intéressante et novatrice puisqu’elle se propose de fusionner les principes du rétablissement psychologique avec ceux de la thérapie cognitive. Elle propose une conceptualisation et une planification du traitement cognitivo-comportemental basé les objectifs de rétablissement du patient, qui se révèle efficace sur les symptômes positifs, négatifs ainsi que sur le fonctionnement général des patients souffrant de schizophrénie. Cet article expose une application de cette approche auprès d’un patient souffrant d’une schizophrénie paranoide, dont l’anosognosie, le refus de suivi et les fréquentes hospitalisations conduisirent à un suivi assertif par une équipe mobile. Le cas clinique illustre comment l’identification d’un objectif de rétablissement personnel puis son fractionnement en sous-étapes quantifiables a permis à ce patient de définir une trajectoire de rétablissement et viser une action positive. Ce travail orienté sur le rétablissement a également servi de cadre au thérapeute pour cibler les croyances dysfonctionnelles sous-jacentes aux symptômes négatifs de ce patient.

Contrary to pessimistic views of schizophrenia as a degenerative condition with poor prognosis, it has been shown over the past decades that individuals with schizophrenia can, to some extent, recover from this severe condition. Recovery is a personal process of growth which refers to “the establishment of a fulfilling, meaningful life and a positive sense of identity” involving four main components: finding hope, defining identity, finding meaning in life and taking responsibility (Andresen et al., 2003). If the importance of implementing recovery-based approaches for people suffering from schizophrenia is nowadays widely acknowledged, it may not be easy to translate recovery principles into specific interventions (Grant et al., 2014). To address this question, Aaron T. Beck et al. have adapted cognitive therapy to develop a recovery-based cognitive approach which specifically aims to treat the psychological factors that challenge the recovery efforts of individuals with schizophrenia. Based on studies showing that psychotic patients’ defeatist beliefs and negative attitudes towards their ability to achieve personal goals induce negative symptoms (Grant & Beck, 2009; Grant & Beck, 2010; Beck et al., 2013), Recovery-oriented Cognitive Therapy (CT-R) focuses on the achievement of personally set goals by overcoming obstacles to their attainment. This approach provides a roadmap to recovery by combining the principles of psychological recovery with those of cognitive therapy: targeting defeatist beliefs and negative attitudes, activating positive attitudes through experimentation and assisting adaptation to life in the community. The efficacy of CT-R was assessed in a randomized controlled trial of low-functioning patients with schizophrenia, showing a beneficial effect on positive and negative symptoms as well as on global functioning (Grant et al., 2012). These improvements were maintained over the course of a six-month follow-up in which no therapy was delivered (Grant et al., 2017). This article presents a case study of CT-R. The patient, Luc, was diagnosed with paranoid schizophrenia and presented symptoms of anosognosia, refusal of care and frequent hospitalizations. This led to intensive Assertive Community Treatment (ACT). The case illustrates how the three steps of CT-R treatment work: 1. Activating the individual's “adaptative mode” instead of “patient mode”: treatment begins with methods to engage patients in the therapy, to create a therapeutic alliance and increase activation. To encourage participation, the therapy strategically aims to increase resources, energy and affect by engaging the patient in pleasurable activities, discussions reflecting their personal interests etc. Clinical issues and formal assessment procedures are avoided at the beginning of therapy; 2. Setting recovery goals and breaking them into smaller concrete steps: collaboratively identifying personal and meaningful goals for the future, valued aspirations and life goals that align with the individual's personal values. Their long-term ambitions are then broken down into concrete sequential steps, creating a roadmap to recovery and allowing the patient to experience small successes through the recovery steps; 3. Using the cognitive model and tools to understand and attenuate obstacles emerging through the recovery steps, such as positive and negative symptoms. Psychotic symptoms and other clinical issues are thus collaboratively considered as obstacles to recovery and become the target of treatment. At the end of the therapy Luc no longer needed an intensive ACT care and was no longer hospitalized. Through the pursuit of his own life goals, he engaged in the therapy, experienced success, reduced dysfunctional beliefs underling symptoms, improved social isolation, gained mastery over his symptoms, and lived a more satisfying and productive life. This case shows how CT-R can promote improvement of symptoms and quality of life in patients with schizophrenia. It illustrates how traditional cognitive therapy and recovery principles can be merged by working on CBT conceptualization and treatment based on patients’ personal recovery objectives for the benefit of individuals struggling with severe schizophrenia.