La compréhension de la schizophrénie s’inscrit aujourd’hui dans un modèle explicatif de vulnérabilité – stress – compétences adaptatives qui nécessite une prise en charge multidimensionnelle. Les courants de réhabilitation psychosociale préconisent ainsi de coupler à la prise en charge médicamenteuse, le soutien socio-familial, la psychoéducation, la remédiation cognitive et l’entraînement aux habiletés sociales (EHS) qui constituent alors autant de facteurs de protection contre les rechutes de la maladie. L’étude de cas ci-dessous, montre chez un patient souffrant de schizophrénie que l’EHS conduit à la diminution de l’anxiété sociale et du retrait social, à l’amélioration de l’estime de soi et de l’assertivité. Le programme proposé au sein d’un établissement médico-social visant la réinsertion socioprofessionnelle de personnes en situation de handicap du fait de troubles psychiatriques, s’inscrit dans une prise en charge pluridisciplinaire s’appuyant sur une approche neuropsychologique et cognitivo-comportementale. L’intérêt de cette étude de cas tient au fait que ce programme se déroule dans un établissement médico-social et non sanitaire, dans lequel les thérapies cognitivo-comportementales, dont l’utilisation auprès d’un public souffrant de troubles psychotiques est loin d’être répandue, trouvent leur place et produisent des résultats intéressants sur l’amélioration du comportement social du patient en lien avec ses symptômes positifs.

Understanding schizophrenia is grounded in the stress – vulnerability – adaptive competence explanatory model [1Deleu G.M. Réhabilitation psychiatrique, plaidoyer pour une formation de base des équipes psychiatriques de secteur  Belgique: Socrate-Editions (2004). 

Cliquez ici pour aller à la section Références], which requires multidimensional therapy, such as that promoted by psychosocial rehabilitation. We now know that poor social skills are a vulnerability factor, which not only aggravate patients’ symptoms but also undermine their inclusion in daily life. Patients with schizophrenia, who have troubled relationships with themselves and others, have a tendency for social withdrawal and avoidance linked to certain delusions, in particular, persecution. In this context, social skills training together with drug therapy, family and social support, psychoeducation and cognitive remediation are all protective factors against relapse [6Wallace C.J., Liberman R.P. Social skills training for patients with schizophrenia: a controlled clinical trial Psychiatry Res 1986 ;  15 (3) : 239-247

Cliquez ici pour aller à la section Références, 7Wallace C.J., Nelson C.J., Liberman R.P., Aitchison R.A., Lukoff D., Elder J.P., et al. A review and critique of social skills training with schizophrenic patients Schizophr Bull 1980 ;  6 (1) : 42-63 [cross-ref]

Cliquez ici pour aller à la section Références, 8Hogarty G.E., Anderson C.M., Reiss D.J., Kornblith S.J., Greenwald D.P., Javna C.D., et al. Family psychoeducation, social skills training, and maintenance chemotherapy in the aftercare treatment of schizophrenia: one-year effects of a controlled study on relapse and expressed emotion Arch Gen Psychiatry 1986 ;  43 (7) : 633-642 [cross-ref]

Cliquez ici pour aller à la section Références]. The basic principles of these interventions are an integral part of the psychosocial rehabilitation programs inspired by cognitive-behavioral therapy. Various studies have shown the efficiency of this therapy in reducing psychotic symptoms and improving self-esteem, quality of life or social adjustment of patients with schizophrenia [9Zaarour Z. La place de la thérapie cognitivo-comportementale dans la schizophrénie : une revue de littérature Rev Med Brux 2008 ; 95-101

Cliquez ici pour aller à la section Références, 10Kingdon D.G., Turkington D. Thérapie cognitive de la schizophrénie[Traduction de Périard P]..   Paris: De Boeck (2011). 

Cliquez ici pour aller à la section Références, 11Abdel-Baki A., Nicole L. Schizophrénie et psychothérapies cognitivo-comportementales Can J Psychiatry 2001 ;  46 (6) : 511-521

Cliquez ici pour aller à la section Références]. The case study presented in this article shows the development of a program offered in a social health care centre aimed at the socio-professional integration of people with psychiatric disorders. The therapeutic approach is part of multidisciplinary treatment based on a neuropsychological and cognitive-behavioral approach. This case was interesting because the program took place in a non-health centre where cognitive-behavioral therapy, which is not widely used with patients with psychotic problems, has a place and produces positive results in the improvement of the patient's social behavior. The patient was a young, 21-year-old man with schizophrenia. At the start of the program he was being treated by a psychiatrist in his local psychiatric unit. He lived with his mother. He wanted to train to become a baker in a vocational training centre. His main complaint was social withdrawal linked to ideas of persecution following a first hospitalization for a brief psychotic disorder. The patient avoided many social situations. According to the initial clinical evaluations, the patient showed low self-esteem, severe social phobia and poor social adaptation. The delusions were well-controlled by medication and the patient had good insight. The program offered social skills training using the game “Competence” [40Favrod J., Aillon N., Bardiot G. « Compétence » : un cheval de Troie dans les soins Cah Psychiatr 1995 ;  18 : 47-53

Cliquez ici pour aller à la section Références], self-assertiveness sessions adapted for schizophrenia, relaxation exercises, cognitive retraining in environmental conditions, interspersed with individual therapy sessions. At the end of the program, which lasted 6 months, we noticed that, in the case of this patient, social skills training had led to a reduction in social anxiety, improved assertiveness and a reduction in social withdrawal linked to a mitigation of the presence of “persecuting looks” in everyday life. We also noticed an improvement in attention abilities of the patient, which could be linked to a decrease in anxious expectations. However, due to the intense relationship with his mother, the patient maintained erroneous beliefs about his professional capabilities and refused a place in a sheltered workshop, which better suited his current overall cognitive abilities. The failure of his career plans showed the importance of working with families. As the length of the program was limited, communication and partnership with the patient's local health team was extremely important to maintain his progress. These different elements show the importance of a multidimensional, integrated, networked approach in the support of patients suffering from psychotic disorders.