Les soins somatiques devenus de plus en plus spécialisés font face à un nombre croissant de patients présentant des comorbidités psychiatriques. Celles-ci peuvent entraîner une perturbation des relations patient-soignants, une diminution de la réponse aux traitements somatiques, ainsi qu’une augmentation de l’utilisation des soins. Face à ces constats, le service de psychiatrie de liaison du centre hospitalier universitaire Vaudois à Lausanne (CHUV) a développé une approche réflexive de type supervision auprès des équipes de soins somatiques. Nous rendons compte ici de cette pratique et de l’importance de s’appuyer sur plusieurs modèles, dans une approche intégrative, afin de mieux appréhender la complexité qui se dégage de la rencontre entre le système patient et celui des soins. La référence aux concepts de « fonction contenante » et de « phénomènes transitionnels », issues du modèle psychanalytique, aide le superviseur à recevoir, contenir et donner du sens aux affects qui émergent et s’entrecroisent dans cet espace. Mais, l’expérience nous montre que le processus de compréhension, pour qu’il puisse être réellement intégré, doit se co-construire entre tous. Le recours à des outils peu conventionnels comme la « sculpture vivante », issue de l’approche systémique, permet au travers de l’expérimentation partagée, cette ouverture vers la découverte de pistes ou d’hypothèses pour, in fine, mieux nous ajuster aux réels besoins de nos patients.
Over the years, somatic care has become increasingly specialized. Furthermore, a rising number of patients requiring somatic care also present with a psychiatric comorbidity. As a consequence, the time and resources needed to care for these patients can interfere with the course of somatic treatment and influence the patient-caregiver relationship. In the light of these observations, the Liaison Psychiatry Unit at the University Hospital in Lausanne (CHUV) has educated its nursing staff in order to strengthen its action within the general care hospital. What has been developed is a reflexive approach through supervision of somatic staff, in order to improve the efficiency of liaison psychiatry interventions with the caregivers in charge of patients. The kind of supervision we have developed is the result of a real partnership with somatic staff. Besides, in order to better understand the complexity of interactions between the two systems involved, the patient’s and the caregivers’, we use several theoretical references in an integrative manner.
The psychoanalytical model allows us to better understand the dynamics between the supervisor and the supervised group in order to contain and give meaning to the affects arising in the supervision space. “Containing function” and “transitional phenomena” refer to the experience in which emotions can find a space where they can be taken in and processed in a secure and supportive manner. These concepts, along with that of the “psychic envelope”, were initially developed to explain the psychological development of the baby in its early interactions with its mother or its surrogate. In the field of supervision, they allow us to be aware of these complex phenomena and the diverse qualities to which a supervisor needs to resort, such as attention, support and incentive, in order to offer a secure environment.
A new perspective of the patient’s complexity is revealed by the group’s dynamics. The supervisor’s attention is mainly focused on the work of affects. However, these are often buried under a defensive shell, serving as a temporary protection, which prevents the caregiver from recognizing his or her own emotions, thereby enhancing the difficulties in the relationship with the patient. Whenever the work of putting emotions into words fail, we use “sculpting”, a technique derived from the systemic model. Through the use of this type of analogical language, affects can emerge without constraint or feelings of danger. Through “playing” in that “transitional space”, new exchanges appear between group members and allow new behaviors to be conceived. In practice, we ask the supervisee who is presenting a complex situation, to design a spatial representation of his or her understanding of the situation, through the display of characters significant to the situation: the patient, somatic staff members, relatives of the patient, etc. In silence, the supervisee shapes the characters into postures and arranges them in the room. Each sculpted character is identified, named, and positioned, with his or her gaze being set in a specific direction. Finally the sculptor shapes him or herself in his or her own role. When the sculpture is complete and after a few moments of fixation, we ask participants to express themselves about their experience. By means of this physical representation, participants to the sculpture discover perceptions and feelings that were unknown up to then. Hence from this analogical representation a reflection and hypotheses of understanding can arise and be developed within the group.
Through the use of the concepts of “containing function” and “transitional space” we position ourselves in the scope of the encounter and the dialog. Through the use of the systemic technique of “sculpting” we promote the process of understanding, rather than that of explaining, which would place us in the position of experts. The experience of these encounters has shown us that what we need to focus on is indeed what happens in this transitional space in terms of dynamics and process. The encounter and the sharing of competencies both allow a new understanding of the situation at hand, which has, of course, to be verified in the reality of the patient-caregiver relationship. It is often a source of adjustment for interpersonal skills to recover its containing function in order to enable caregiver to better respond to the patient’s needs.
Mots clés : Supervision, Psychiatrie de liaison, Fonction contenante, Espace transitionnel, Sculpture vivante
Keywords : Supervision, Liaison psychiatry, Containing function, Transitional space, Sculpting
Vol 39 - N° 3P. 232-236 - juin 2013 Retour au numéro
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