La réhabilitation psychosociale vise l’autonomie psychosociale de la personne handicapée par ses troubles psychiques et la reprise d’une vie sociale et professionnelle effective. Nous étudions, au sein d’une structure de réhabilitation psychosociale, l’influence de l’alliance thérapeutique et de l’insight sur les habiletés psychosociales, la qualité de vie et l’insertion professionnelle pour cinq sujets souffrant de schizophrénie. Les résultats montrent l’importance de l’influence probable de l’alliance thérapeutique sur l’évolution des sujets et la difficulté à se saisir de façon opérationnelle et cliniquement pertinente du concept d’insight. Les résultats restent difficilement généralisables compte tenu du faible effectif et encouragent des études sur un plus grand nombre de sujets.

The aim of psychosocial rehabilitation is to help people disabled by mental illness become self-sufficient and return to a healthy social and professional life. Some approaches to psychosocial rehabilitation such as supported employment, family psycho-education or skills training have shown their effectiveness in terms of employability. At the Service d’aide à l’insertion professionnelle des personnes handicapées (SAIPPH), a professional rehabilitation service for people with disabilities, we studied the influence of therapeutic alliance and insight on life skills, quality of life and employability of five subjects with schizophrenia. To do this, we used both quantitative data (psychological assessments) and qualitative data (analysis by rehabilitation workers) collected on entry into the service and after three and ten months of treatment. The quantitative results show that, at the start, the group had fairly good therapeutic alliance and fairly good insight that changed little. Psychosocial skills, quality of life and, in particular, securing employment progressed between entry into the service and after ten months of treatment. With regard to our hypothesis (therapeutic alliance and insight as predictors of the evolution of subjects), a positive correlation between therapeutic alliance and progression of subjects was noted. On the other hand, the results showed a strong but negative link between insight and improvement in the subjects: the more insight they had, the less they improved (or were aware of improving). Although this may seem paradoxical, this result was coherent with certain results from studies on insight. Finally, there was a strong and negative link between service intensity, professional activity and quality of life. It seems likely that subjects who spend the longest time in this type of program have the most difficulty adapting to other environments. The qualitative part of this study highlighted the uniqueness of the experiences of five service users. Frédéric, aged 30, was on sick leave and wanted support for retraining. His experience seemed to validate our hypothesis as he improved during his stay (work, social skills, quality of life) while he showed pretty good insight at the start, and above all, had a good relationship with his rehabilitation counselor. Gabriel, aged 28, wished to train as an electrician. His experience partly confirmed our hypothesis. In fact, he had quite low insight and average therapeutic alliance but that did not prevent moderate positive development in his social skills and quality of life. Even if his rehabilitation remained limited and weak, there was progress. Benoît, aged 37, wanted assistance in finding employment in a sheltered workshop. His experience contradicted our hypothesis. While initially his insight, therapeutic alliance and service intensity were fairly good, this did not preclude great difficulties in rehabilitation which finally resulted in failure and return to care. Michel, aged 39, required help in finding a sheltered workshop. Average insight and alliance did not prevent him from making good progress, in spite of poor service intensity. However, he had strong alliance with his psychiatrist, which could have been the motor behind his improvements, partly confirming our hypothesis on the influence of alliance. Mathieu, aged 35, requested help in finding a sheltered workshop. It was particularly difficult to interpret his experience as, on one hand, results of the questionnaire showed good insight and good alliance as well as good social and professional growth, which was consistent with our hypothesis. But, on the other hand, caregivers perceived his insight and alliance as a “facade”, which was shown by his apparent lack of positive criticism of symptoms (delusions and eating disorders). In conclusion, this study suggests that therapeutic alliance has an important influence on the evolution of subjects. The results remain difficult to generalize given the small number of subjects, and studies on a greater number of participants should be carried out.