Acknowledging caregivers' vulnerability in the managment of challenging behaviours to reduce control measures in psychiatry.

BACKGROUND: The management of challenging behaviours in inpatient with intellectual disability and/or autism spectrum disorders can lead to an escalation of control measures. In these complex situations where patients have an intellectual disability/autism spectrum disorder accompanied by a psychiatric comorbidity, the experiences of caregivers related to the crisis management have rarely been studied. PURPOSE: This study examined the moral experiences of caregivers related to challenging behaviours' management and alternatives to control measures. RESEARCH DESIGN: Using Charles Taylor's hermeneutic framework, a 2-month focused ethnography with a participatory approach was used. PARTICIPANTS AND RESEARCH CONTEXT: Sixteen caregivers were interviewed in a Canadian mental health setting for adults with intellectual disability/autism spectrum disorder and psychiatric comorbidity. ETHICAL CONSIDERATIONS: The research was conducted in compliance with the Declaration of Helsinki and local Research Ethics Board approval. Written informed consent was collected systematically from participants. FINDINGS: By accounting for caregivers' moral experiences, this study sheds light on a neglected dimension of the care relationship: the vulnerability of the caregiver. We highlight the main barriers and facilitators to alternatives to control measures. First, a caregiver's vulnerability was characterised by the overall impact of challenging behaviours and the moral distress associated with the use of control measures and exclusion mechanisms of intellectual disability/autism spectrum disorder patients. Second, a strong ambiguity between care and control measures and a lack of inclusive approaches were identified as the two main barriers to challenging behaviour management. Third, the involvement, both professional and personal, of caregivers was deemed necessary to implement alternatives to control measures. DISCUSSION: A conflict of values opposes two conceptions of autonomy: a rational autonomy, which is counterproductive to the reduction of control measures, versus a relational autonomy based on shared vulnerability. CONCLUSION: The recognition of caregiver's vulnerability is a benchmark to create alternative approaches, which defuse the logic of control and promote an ethics of care within which caregivers' self-concern can be understood as fostering mutual respect.

[10 years of public mental health services for asylum seekers persons in Geneva What balance? Which new horizons?] / Dix ans de soins psychiatriques communautaires auprès des personnes requérantes d'asile à Genève - Bilan et perspectives.

Transcultural psychiatry in the public sector is specifically linked to current political events. The recent ukrainian crisis is an illustration of how massive displacement of refugees can occur. Recently, the COVID-19 pandemic had consistently and in many ways weakened the vulnerable population of asylum seekers. These two major events remind us how flexible and reactive our care settings have to be, how much we need to collaborate with our partners in order to maintain creativity and quality in our interventions.

La pratique de la psychiatrie transculturelle en institution se caractérise par un lien constant entre l'actualité mondiale et nos dispositifs de soins. La toute récente crise ukrainienne illustre la rapidité avec laquelle d'importants flux migratoires peuvent soudain être déclenchés. Auparavant, la pandémie de Covid-19 avait déjà fragilisé, par différents aspects, la population vulnérable des personnes requérantes d'asile. Ces deux événements majeurs nous rappellent à quel point nos dispositifs de soins se doivent d'être souples et réactifs et capables de s'articuler avec d'autres partenaires afin de maintenir une créativité et une qualité dans nos soins.

Effectiveness of a therapeutic multiple-lifestyle intervention taking into account the periconceptional environment in the management of infertile couples: study design of a randomized controlled trial - the PEPCI study.

BACKGROUND: Infertility is defined as the inability to conceive after 12 months of unprotected intercourse. It affects approximately one in six couples seeking pregnancy in France or western countries. Many lifestyle factors of the couples' pre and peri-conceptional environment (weight, diet, alcohol, tobacco, coffee, drugs, physical activity, stress, sleep…) have been identified as risk factors for infertility in both males and females. The high prevalence rates of unhealthy diets and lifestyles in the reproductive population of industrialized countries are worrisome. Nevertheless, adoption of a healthy lifestyle may improve fertility but lifestyle changes are difficult to achieve and to maintain due notably to behavioral factors. METHODS: Consequently, we decided to propose an interventional study aimed at improving the quality of life of infertile couples before the start of assisted reproductive technology treatment. It is a randomized controlled multicentre trial. Both members of the couples are involved in an integrated global care program (PEPCI for "Parcours Environnement PériConceptionnel en Infertilité") vs. usual care. This global intervention not only considers diet and/or physical activity but follows a holistic approach, including a multidisciplinary assessment to address complete physical, psychological and social well-being. According to patient needs, this includes interventions on weight, exercise, diet, alcohol and drugs, mental and social health. DISCUSSION: The main objective of trial is to demonstrate that periconceptional multidisciplinary care has a positive impact on reproductive functions. We will also focus on feasibility, acceptance, compliance and conditions of success of a multifaceted lifestyle intervention. TRIAL REGISTRATION: The trial was registered at ClinicalTrials.gov, Identifier: NCT02961907 on November 11, 2016.

Care and prejudice: moving beyond mistrust in the care relationship with addicted patients.

Social representations of addiction and the resulting stigmatization have been widely described and studied in the literature, but their effects are no less problematic. These representations, which also occur in care settings, generate a climate of distrust which damages the therapeutic relationship, and its ethical quality. This article, combining clinical experience and an ethical stance, offers an original, innovating approach to the existence of distrust in care relationships in the area of addiction. Pragmatic approaches deriving from the human sciences and analytical philosophy provide an invitation to escape from the demanding climate of mistrust, and to take the gamble on trust so as to improve the quality of interactions between protagonists in care. In complementary fashion, a sociology of action can combat the disquiet generated by distrust through a new commitment to innovating forms of action. This "poetic" mode of action is legitimized by the reflection that backs it up, and by its presentation to peers qualified to approve it. Finally, continental moral philosophy underlines the importance of a carefully weighed commitment on the part of caregivers and addicted patients towards promises aiming to support a sincere care relationship, without damaging the therapeutic dynamic or the ethical quality by providing too many safety nets. This reflection is intended to achieve better identification of the clinical and ethical issues raised by mistrust, and inclusion of these aspects in the training of personnel and in care provision planning.

[Building a care relationship in the home of drug-addicted parents]. / Construire une relation de soins au domicile des parents addictés.

Professionals' visits to the home of drug-addicted parents are a way of constructing a flexible and original framework.Whether the objective is simply to create the opportunity for the parties to meet with each other or to carry out intensive and complex treatment, it involves establishing the conditions for a trust relationship between the parents, children and partners.

[Pregnancy and parenthood in the context of addiction]. / Grossesse et accession à la parentalité en contexte d'addiction.

Addictive behaviour in the perinatal period gives rise to significant health risks for the infant and the mother. When the experience of new parenthood coincides with the problem of addiction the parents' psychological problems can be intensified. These specific issues, sometimes difficult for the teams to have to deal with, require the creation of a complex and coordinated care programme.

[Adolescents and young adults in situations of addiction]. / Adolescents et jeunes adultes en situation d'addiction.

Adolescence is a period of major readjustments during which experimenting with psychoactive substances is common and can, in some cases, lead to the development of long-term addictive behaviour. Identifying young people with a particular vulnerability for the development of such behaviour and offering them adapted support is therefore an important part of the care provided to adolescents.

[Does the use of psychoactive drugs in adolescence create specific problems?]. / Usages de psychotropes à l'adolescence, des problématiques spécifiques?

The use of psychoactive drugs by teenagers presents commonalities and specificities depending on the substances used. The connection noted between the early age of use and the onset of harm, supports the recommendation of early interventions targeting all drugs. However, drug use differs according to the type of substance, highlighting the need to take into accountthese specificities in addiction therapy.

Impact of migration on explanatory models of illness and addiction severity in patients with drug dependence in a Paris suburb.

Objectives of this study were to assess explanatory models (considering illness experience and meaning), addiction severity among patients with drug dependence, and the role of migration. Adapted Explanatory Model Interview Catalogue interviews were conducted with 70 outpatients in a Paris suburb. Among them, 42 were either first- or second-generation immigrants, most from North Africa. Explanatory models were analyzed qualitatively and quantitatively according to migration status, assessing potential confounders with multivariate linear models. Explanatory models were heterogeneous. Compared with nonmigrants, migrants reported fewer somatic and violence-related symptoms. They attributed the causes of their addiction more frequently to social and magico-religious factors and less to psychological factors. Conversely, no difference in addiction severity was found between migrants and nonmigrants. Considering local patterns of illness experience and meaning of drug dependence is a critical component of culturally sensitive clinical care.

[Taking care of the families of air disaster victims]. / La prise en charge des families de victimes d'une catastrophe aérienne.

The medico-psychological emergency unit in Seine-Saint-Denis (93) was involved in managing the families of the victims of the AF447 flight crash which took place on the night of 31 May and 1 June 2009 between Rio de Janeiro (Brazil) and Paris. It is interesting to study the system set up at the airport, the symptomatology observed, and the parameters of the efficiency of the care provided.

The benefits of mindfulness-based interventions on burnout among health professionals: A systematic review.

OBJECTIVE: Healthcare professional burnout affects performance and has a negative impact on healthcare as a whole. Mindfulness-based Interventions (MIs), developed over the last 30 years, are increasingly used by healthcare professionals to reduce the risk of burnout. Yet the impact of MIs on burnout remains to be clarified. This review aimed to summarize and evaluate the existing literature on the potential benefits of MIs to minimize burnout risk. METHODS: We conducted a systematic review of the literature, reporting according to the PRISMA standards. PubMed, Psychinfo, Web of Science and Science Direct databases were screened for original articles. Articles in English assessing an MI in combination with burnout measures were included up to September 2018. RESULTS: Thirty-four articles were included. Only four randomised controlled trials concluded to burnout improvement after several weeks of MIs (11,8%). In the remaining five randomised controlled trials, results did not reach statistical significance. Of the four controlled, non-randomised studies, three showed significant improvements on burnout. Twenty-one studies did not report a controlled trial design. Overall the results appeared to be widely heterogeneous and several methodological concerns arose from the review. CONCLUSION: This review shows the overall insufficient level of evidence offered by the literature assessing the effects of MIs on burnout in health professional populations. However, some studies have reported promising results and future research should address methodological issues and define more precise contexts of interventions and target populations that could benefit from MIs.

Excessive substance use screening to encourage behaviour change among young people in primary care: Pilot study in preparation for a randomized trial.

INTRODUCTION: Alcohol, cannabis and other substance use affects young people's health. Primary care physicians are encouraged to screen and provide brief interventions for substance use in this population, but implementation is often limited. Pre-consultation self-administered screening may decrease at-risk substance use and could have population-level benefits. A randomized controlled trial is planned to test this hypothesis. The present pilot study's objective was to assess the feasibility of methods for the future trial. METHODS: The parallel-group randomized controlled pilot trial was undertaken in 6 primary care practices in Geneva, Switzerland, over 2 months. 29 patients aged 15-24 years consulting for any reason were randomly assigned to intervention (substance use screening, n = 14) or control (physical activity questionnaire, n = 15) using computer-generated random number tables. Outcomes were assessed one month later by telephone questionnaire. Physicians, practice staff and outcome assessors were blinded to allocation. The primary outcomes were feasibility of procedures and acceptability to participants, primary care physicians and practice staff. RESULTS: Of 16 participants reached at follow-up, 3 reported excessive substance use. Methods were acceptable to all participants, especially regarding confidentiality. Three participants were lost due to technical difficulties with the consent form. No major problems with study methods were reported in the practices. 4 practices did not meet recruitment targets. CONCLUSION: The study procedures proved to be feasible in primary care practices and acceptable to young people who were readily available to participate. The main challenge for the future full-sized trial will be to ensure that recruitment targets can be met.

"If walls could talk": A photo-elicitation-based observation of service users' perceptions of the care setting and of its influence on the therapeutic alliance in addiction treatment.

A good quality therapeutic alliance is central to the support and treatment of people who use psychoactive substances. Although previous research has suggested that place has an important role in sustaining the therapeutic alliance, this issue has been insufficiently explored in the field of addiction treatment. We conducted a qualitative study using photo-elicitation and interviewing service users in an outpatient addiction treatment centre. They reported both strongly positive and negative perceptions of the place, alongside an unstable therapeutic alliance. Apprehending the place in which care is delivered as a dynamic relational network helps to understand the role of place in shaping the therapeutic alliance in addiction treatment. There is a need for careful design and layout, and thoughtful organisation of these places.

Overcoming professionals' challenging experiences to promote a trustful therapeutic alliance in addiction treatment: A qualitative study.

BACKGROUND AND AIMS: A good therapeutic alliance plays a major role in the healing process. Professionals working in addiction treatment report high levels of psychological distress related to work and this may challenge the establishment of a trustful therapeutic alliance, and lead to a loss of care quality provided to service users. The purpose of this study was to investigate the experience of specialized professionals, its effects on trust and the therapeutic alliance, and the means to restore them. DESIGN: We conducted a qualitative study using a semi-structured questionnaire and a narrative tool. Discourse was extracted from focus groups and individual interviews and analyzed following the Interpretative Phenomenological Analysis method. PARTICIPANTS: Twenty-six professionals from three addiction treatment centers in the Paris area were interviewed. FINDINGS: The difficulties weighing on the care alliance were described by the participants in terms of their nature, their effects and means to overcome them. Emotional drain leads to a climate of relational distrust and the temptation to desert or over-control patients. Teambuilding, specific training and self-care are viewed as means to restore a therapeutic alliance based on an appropriate type of trust. CONCLUSIONS: Distrust deriving from professionals' challenging experiences may lead to worrying consequences. Promoting democratic organization of care structures, specific training, and also responsible self-care on the part of professionals could help to restore a type of trust that helps to establish a therapeutic alliance suited to service user individualities. This could ultimately be beneficial for user care, professional wellbeing and team functioning.