Approche motivationnelle auprès des auteurs de violences sexuelles : état de la littérature et aspects cliniques - 30/05/15
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Résumé |
En France, le suivi sanitaire des sujets condamnés pour des infractions sexuelles en milieu ouvert ambulatoire s’effectue généralement dans le cadre des soins pénalement ordonnés : obligations ou injonctions de soins. Les prises en charge de ces auteurs se heurtent régulièrement à des difficultés diverses, inhérentes aux aspects cliniques, thérapeutiques, interrelationnels au cadre médico-judicaire. À travers la question sensible de la formulation de la demande de suivi par les patients émergent les dimensions de volonté de changement et de motivation au traitement, notamment chez les patients présentant un discours de dénégation totale ou partielle des faits. Considérant le modèle motivationnel de Miller et Rollnick, il est fréquent de constater que les auteurs de violences sexuelles se situent généralement aux stades de précontemplation et de contemplation de leurs difficultés et que les facteurs motivationnels au changement sont surtout extrinsèques (cadre judiciaire, pression de l’entourage, etc.). La résistance au changement peut apparaître sous des formes différentes et aboutir à un arrêt du suivi. L’adaptation des techniques d’entretien motivationnel apporterait des bénéfices dans le suivi de ces patients, en termes d’adaptation aux rythmes individuels, d’engagement et de responsabilisation. Cela proposerait un outil thérapeutique pertinent et resituerait l’approche motivationnelle dans le mouvement d’approches dites « positives » développées depuis quelques années (Good Lives Models, désistance, prise en compte des facteurs de protection, etc.) en complément des approches dites de gestion des risques de récidive. Après des rappels cliniques et de principes généraux de prises en charge, nous présenterons l’état de la littérature concernant l’utilisation de l’entretien motivationnel chez les auteurs de violences sexuelles et développerons l’intérêt de cette approche.
Le texte complet de cet article est disponible en PDF.Summary |
In France, the health monitoring of convicted sex offenders in outpatient units generally takes place within the context of court-ordered treatment: obligation or medical treatment order (Cochez et al., 2010). The treatment of sex offenders (SO) is often met with a variety of difficulties inherent in the clinical, therapeutic and inter-relational nature of the medico-legal context. This is particularly true with regard to the quality of the patient's consent to treatment, the demand for care which can be utilitarian, the psychological functioning of SO (often labelled personality disorders rather than genuine psychiatric disorders) or negative attitudes of professionals working with SO: Cochez et al. (2010), Goumilloux et al. (1995), Senon et al. (2006), and Brami (1998). The sensitive question of the patient's request for treatment reveals willingness to change and motivation for the treatment, in particular in the case of patients expressing a total or partial denial of the facts. As far as we know, little French research has been carried out on the question of motivation for change in SO even though this subject is increasingly covered in international literature. Balier's 1997 study, carried out on 176 French SO, gives a first impression of patients’ wish to change at a time when court-ordered treatment was not yet introduced. This research showed us that more than 2/3 of subjects wished to change and that 54% had already made steps towards changing. It also revealed that certain factors seemed to be associated with a stronger desire to change, such as feelings of guilt, of the abnormality of their act or expressions of responsibility for the act and recognition of the consequences for the victims. Furthermore, according to Miller and Rollnick's motivational model (2002), sex offenders are often noted to be generally in the stages of precontemplation and of contemplation of their difficulties and factors relating to motivation for change are predominantly extrinsic (legal context, peer pressure,…). International literature suggests certain factors as levers or barriers to motivation for change. These factors can be socio-demographic, for example, the age of the subject, their culture, their education, but also their income: Burrowes et al. (2009). These factors can also be data-linked to personality traits such as impulsivity or emotional instability (Weiner, 1986) or developmental or cognitive factors such as cognitive schemas, cognitive distortions, denial and lack of empathy, rigidity and the perception of life objectives and attachment style: see Hildebran (1989), Larsen (1995) and Pollock (1996). Finally, environmental factors, such as family or socio-political environment, influence the wish to change: Burrowes et al. (2009), Sefarbi (1990), and Stevenson et al. (1989). In addition, strong links exist between compliance to therapeutic treatment and motivation for change. A refusal to participate in a therapeutic activity is spontaneously linked to an absence of motivation for change. Literature provides information on the complex links between therapy and the motivation for change and indicates that refusal to participate is not always linked to a lack of motivation for change, but could be a sign of fear associated with the activity or its consequences. Furthermore, behaviour of the patient's support network, in the widest sense of the term, can influence compliance to therapeutic treatment. The attitude of the therapist before and during treatment is also a very important factor in the patient's commitment to the treatment programme: Tierney et al. (2002), Miner et al. (1995). Adapting the techniques of motivational interviewing could be beneficial in the treatment of these patients, in terms of adaptation to individual rhythms, commitment and accountability. It offers a pertinent therapeutic tool and regroups the motivational approach with other “positive” approaches developed over the last few years (Good Lives Models, desistance, consideration of protective factors,…) to compliment “risk of recidivism” approaches: see Raymond (2011) and Mc Kay et al. (1996). Clinical histories and general principles of treatment will be presented followed by a literature review on the use of motivational interviewing with sex offenders. The value of this approach will then be considered.
Le texte complet de cet article est disponible en PDF.Mots clés : Motivation, Changement, Thérapie, Auteurs de violences sexuelles, Violence
Keywords : Motivation, Change, Motivational interviewing, Sex offenders, Violence
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Vol 25 - N° 2
P. 48-57 - juin 2015 Retour au numéroBienvenue sur EM-consulte, la référence des professionnels de santé.
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