Le silence comme outil thérapeutique dans la dépression : élaboration théorique basée sur une étude de cas
Abstract
À l’aide d’un exemple clinique, nous élaborons les différentes fonctions que peut avoir le silence dans les thérapies cognitives et comportementales de la dépression. Les silences d’une patiente déprimée, suivie en psychothérapie, sont documentés et analysés. Le silence peut, chez la même personne, tantôt produire un apaisement ou organiser la pensée, donc s’avérer productif, tantôt représenter une tentative d’échapper à du matériel douloureux, donc s’avérer peu productif. Ainsi, le thérapeute aura fondamentalement le choix, soit de respecter ces silences soit de les rompre et de parler. Pour l’aider dans ce choix, nous repérons différentes catégories de silences et les mettons en lien avec la littérature à ce sujet, afin d’introduire le silence comme outil thérapeutique à part entière dans le traitement cognitivo-comportemental de la dépression.
... vengeance contre la mère ou comme une tendance à l'autopunition. Toujours dans le versant régressif, le silence serait décrit comme une expression de la peur de l'abandon et de la mort (Kaftal, 1980 Le silence serait un indicateur de processus aussi variés que la communication, la lutte transférentielle (Fliess, 1949), l'atténuation de l'émotion (Gendlin, 1996) (Richard & Kramer, 2013). ...
La question originelle de ce travail doctoral a été : comment pense-t-on son histoire de vie au seuil de sa mort ? La fin de vie amène de nombreux bouleversements psychiques et physiques, souvent inhérents à une maladie grave. Le patient est alors amené à se refaire le film de sa vie, à repenser aux événements marquants de son existence. Plusieurs interventions, comme la rétrospective de vie, ont proposé d’accompagner ce processus chez le patient afin que ce dernier puisse voir sa vie comme un « tout cohérent » mais restent à ce jour peu étudiées dans le domaine des soins palliatifs en France. Pour nous aider à répondre à ce questionnement, nous avons mené une première étude auprès de patients en fin de vie dans le but de recueillir le travail cognitivo-émotionnel actuel, d’identifier le type de réminiscences présentes ainsi que la place du silence dans le discours. A l’issue de cela, nous avons conduit une revue parapluie qui nous a permis de recenser les différents éléments nécessaires à la bonne mise en place d’interventions basées sur l’histoire de vie en soins palliatifs, les variables les plus étudiées et les tailles d’effet associées. Grâce à ces deux premiers travaux, nous avons pu mettre en place un accompagnement basé sur la rétrospective de vie chez des patients hospitalisés en soins palliatifs. De cette expérience, nous avons identifié les freins et leviers d’une telle procédure, évaluer son acceptabilité et sa viabilité auprès des patients et décrit les contenus qualitatifs et quantitatifs recueillis. L’ensemble de nos études nous a permis, dans un dernier temps, de proposer des recommandations à l’attention des psychologues ainsi que de proposer de futures recherches pour poursuivre ce travail.
Les etudes de cas en psychotherapie connaissent une phase de renouveau aupres des chercheurs en psychotherapie et des psychotherapeutes. L’auteur discute de deux paradigmes qui ont grandement influence ce nouvel interet : le paradigme pragmatique et le paradigme qui vise la construction d’une theorie. L’article presente les origines, les developpements et les concepts cles des deux paradigmes et leurs specificites methodologiques et ethiques. Des exemples d’etudes de cas ou de modeles au sein des paradigmes sont evoques. L’influence differentielle des courants postmodernes sur les deux paradigmes, et leurs apports respectifs dans le champ des methodes d’etudes de cas, sont discutes et evalues par rapport aux implications pour le chercheur et le psychotherapeute.
Empirical studies examined silences in psychotherapy by measuring the duration of pauses and studying this variable as a homogeneous factor. This approach produced a body of inconclusive findings dealing with the relation between silences and therapeutic outcome or alliance. In the present study, interpersonal process recall interviews of 7 clients' self-reported experiences of in-session pauses were analyzed. A qualitative analysis, based on grounded theory methodology, was used. In this inductive process, researchers are guided by the analysis of data to develop an understanding of phenomena grounded in empirical observation. A pausing inventory of 7 categories was generated, reflecting an understanding of silences as heterogeneous phenomena, and included disengaged pauses, emotional pauses, interactional pauses, reflexive pauses, expressive pauses, associational pauses, and mnemonic pauses. This categorization of pauses can facilitate attunement to client pausing experiences both in future research and in the performance of psychotherapy.
Conducted an intensive, qualitative analysis of borderline and non-borderline client's and therapist's experiences of metaphoric expression in a single psychotherapy session. Open-ended interviews were conducted with 2 therapists and 4 clients (aged 24–38 yrs; 2 borderline and 2 non-borderline) who were actively engaged in psychoanalytically-oriented, long-term psychotherapy. The intensive analyses of inquiry interview transcipts revealed 3 important categories of metaphor functions that were shared by all 4 psychotherapy dyads: (1) metaphors illuminate clinical issues, (2) metaphor functions to depict clients' self and object relationships, and (3) therapist metaphor stimulates an intensification of client experiential engagement in therapy. Patterns differentiating the borderline and non-borderline dyads in relation to metaphor use were discussed in the context of 2 core categories: the Representation Mode of Interaction and the Literal Mode of Interaction. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Fast-acting medications for the management of anxiety are important to patients and society. Measuring early onset, however, requires a sensitive and clinically responsive tool. This study evaluates the psychometric properties of a patient-reported Global Anxiety-Visual Analog Scale (GA-VAS).
Data from a double-blind, randomized, placebo-controlled study of lorazepam and paroxetine in patients with Generalized Anxiety Disorder were analyzed to assess the reliability, validity, responsiveness, and utility of the GA-VAS. The GA-VAS was completed at clinic visits and at home during the first week of treatment. Targeted psychometric analyses--test-retest reliabilities, validity correlations, responsiveness statistics, and minimum important differences--were conducted.
The GA-VAS correlates well with other anxiety measures, at Week 4, r=0.60 (p<0.0001) with the Hamilton Rating Scale for Anxiety and r=0.74 (p<0.0001) with the Hospital Anxiety and Depression Scale-Anxiety subscale. In terms of convergent and divergent validity, the GA-VAS correlated -0.54 (p<0.0001), -0.48 (p<0.0001), and -0.68 (p<0.0001) with the SF-36 Emotional Role, Social Function, and Mental Health subscales, respectively, but correlated much lower with the SF-36 physical functioning subscales. Preliminary minimum important difference estimates cluster between 10 and 15 mm.
The GA-VAS is capable of validly and effectively capturing a reduction in anxiety as quickly as 24 hours post-dose.
Over 90% of therapists self-disclose to clients (Mathews, 1989; Pope, Tabachnick, & Keith-Spiegel, 1987; Edwards & Murdock, 1994), however, the implications of therapist self-disclosure are unclear, with highly divergent results from one study to the next. The goal of this paper was to review the empirical literature relevant to therapist self-disclosure, and provide the reader with a comprehensive understanding of the factors that affect, and are affected by, therapist self-disclosure. Findings are organized into an integrated model examining the who, what, when, why, and how of therapist self-disclosure. In addition, training implications and suggestions for future research are provided.
Self-disclosure, which consists in revealing personal information about oneself to one's client, could be a beneficial therapeutic technique. There are yet many definitions of this concept. However, empirical research shows that self-disclosure may be favourably perceived by clients and that it could influence how they perceive their therapist. Moreover, it could positively influence treatment outcome. Self-disclosure about immediate feelings in the therapy and about the therapist–client relationship would be particularly effective in resolving problematic events by enabling feelings to be expressed and accepted and by providing clients with interpersonnal learning. Several authors finally advise using this technique infrequently, about moderately intimate but relevant themes in relation to the therapy, examining each client's specific needs, and always with the intention of helping them or improving the therapeutic relationship.
Individual variation in the use of symbolic aspects of the treatment situation has been theorized across client groups of varying developmental profiles. In particular, the use of metaphor is thought to be different in the therapies w i t h Borderline clients. The present study involved an intensive qualitative analysis of metaphor-ic expressions from Borderline and non-Borderline psychotherapy sessions. Open-ended interviews were conducted with 2 therapists and 4 clients (2 Borderline; 2 non-Borderline) following single ses-sions from psychoanalytically oriented long term psychotherapies. The analysis of data found significant differences in the therapeutic interaction which led to the major core categories of (a) Literal Mode of Interaction and @) Representational Mode of Interaction, repre-senting the Borderline and non-Borderline sessions respectively. The characteristics of these two modes underscored the differences found Brian Rasmussen, PhD, is afiiliated with the Department of Social Work,
The construction of a depression rating scale designed to be particularly sensitive to treatment effects is described. Ratings of 54 English and 52 Swedish patients on a 65 item comprehensive psychopathology scale were used to identify the 17 most commonly occurring symptoms in primary depressive illness in the combined sample.
Ratings on these 17 items for 64 patients participating in studies of four different antidepressant drugs were used to create a depression scale consisting of the 10 items which showed the largest changes with treatment and the highest correlation to overall change.
The inter-rater reliability of the new depression scale was high. Scores on the scale correlated significantly with scores on a standard rating scale for depression, the Hamilton Rating Scale (HRS), indicating its validity as a general severity estimate. Its capacity to differentiate between responders and non-responders to antidepressant treatment was better than the HRS, indicating greater sensitivity to change. The practical and ethical implications in terms of smaller sample sizes in clinical trials are discussed.