Essai de mise en place de la réhabilitation psychosociale au CNHUP de Cotonou : à propos de deux cas

Les psychotropes sont rarement suffisants dans le traitement des psychoses chroniques et une approche multidisciplinaire du patient est souvent nécessaire. L’objectif de cet article est de montrer la place des thérapies comportementales et cognitives dans le traitement des troubles schizophréniques. Deux patients souffrant de schizophrénie du centre national hospitalier et universitaire de psychiatrie (CNHUP) de Cotonou ont bénéficié de la technique d’entraînement aux habilités sociales dans le but d’acquérir des compétences afin de mieux gérer au quotidien leur traitement, leur équilibre familial et leurs relations interpersonnelles. Les modules d’entraînement proposés concernaient l’hygiène corporelle, les habiletés de conversation et de loisir, et l’éducation au traitement neuroleptique. Ce type d’intervention a permis d’accroître les compétences cognitives et sociales de ces patients. Les durées d’hospitalisation étaient réduites, la fréquence des hospitalisations diminuée et les capacités d’adaptation socio-familiale améliorées. L’efficacité des programmes de réhabilitation des états psychotiques chroniques est signalée par plusieurs auteurs soit en monothérapie, soit en association avec la chimiothérapie. La variabilité des résultats obtenus découle de divers facteurs. Les thérapies comportementales et cognitives permettent d’élargir les possibilités thérapeutiques proposées aux patients souffrant de schizophrénie. Leur mise en œuvre présente un intérêt particulier dans la réhabilitation psychosociale des patients souffrant de psychose chronique.

Introduction

Chemotherapy alone is rarely sufficient in the treatment of chronic psychoses and recently there has been growing interest in the rehabilitation of the patient and their family. However, no previous research on the psychosocial rehabilitation of patients suffering from schizophrenia has been carried out in Benin.

Aim

The aim of this study was to highlight the importance of psychosocial rehabilitation cognitive-behavioral techniques in the treatment of patients suffering from schizophrenia.

Method

Two patients from the Centre national hospitalier et universitaire de psychiatrie (National University Hospital Centre for Psychiatry) in Cotonou suffering from schizophrenia were offered psychosocial skills training with the objective of acquiring rehabilitation skills. The program was preceded by motivational interviews based essentially on open questions, reflective listening and summaries. Discussions focused on the advantages of such a program and the secondary benefits of taking responsibility for their own care. The importance of making changes as well as the ability to do so were also considered. A therapeutic contract allowed patients and therapists to commit to and respect each stage of the programme. Rehabilitation activities were carried out in the form of modeling participation and focused on three modules: bodily hygiene (learning to respect a regular waking time, washing oneself, preparing a meal and washing-up), conversation and leisure skills (increasing leisure time, participating in group activities or institutional meetings, taking part in an art therapy workshop), psychoeducation (information concerning the treatment of the illness, conditions for efficiency of prescribed medication and its undesirable effects, adaptation of doses, prevention and treatment of secondary effects). The program was run by a group of therapists composed of psychiatrists and psychologists, following a clinical evaluation of symptoms based on DSM-IV-R criteria as well as a functional analysis inspired by the BASIC IDEA scale which allowed the diagnosis of deficit schizophrenia. The program lasted three months: one month per module at a rhythm of four hours a week (16 hours per module in total). At the end of the therapy, the patients were seen on a monthly basis over a period of three months. The degree of implication was assessed using a rating scale, which evaluated performance carrying out prescribed tasks during therapy. Relatives of the patients were interviewed over a period of one to two months following the therapy to obtain a subjective and qualitative measure of progress made.

Results

This type of intervention enabled the patient to develop behavioural, cognitive and social skills. The length of hospital stay was reduced, the frequence of hospitalizations diminished and sociofamilial adaptation skills were improved.

Discussion

The efficiency of rehabilitation programmes for chronic psychotic conditions is highlighted by several authors, either as monotherapy, or in association with chemotherapy (Azaïs and Ganger, 1997). The variability of the results obtained is due to several factors and requires motivation on the part of the patient (Konen et al., 1993). Behavioral and cognitive techniques of psychosocial rehabilitation enable a wider range of therapeutic possibilities to be offered to patients suffering from schizophrenia. In general, they allow patients to better understand the evolutive aspects of their illness and to better manage treatment in agreement with the prescriber. These therapies are particularly interesting in the psychosocial rehabilitation of patients suffering from chronic psychosis who relearn, acquire and develop skills progressively through role-play in the repetition of tasks, reinforcement, observation of others and behavioral modeling.

Conclusion

The practice of psychosocial rehabilitation techniques seems to be an important variable in the treatment of patients suffering from schizophrenia but it is still little used in Benin, as in other African countries, due to lack of qualified personnel. The results from this study should incite psychiatric services and hospitals to develop similar programmes.