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Expérience d’un groupe motivationnel tabac auprès d’une population psychiatrique en établissement et service d’aide par le travail - 11/06/13

Doi : 10.1016/j.jtcc.2012.12.001 
Romain Lemaréchal , Louis Lebocey
Maison des addictions (centre de soin, d’accompagnement et de prévention en addictologie), 41, avenue Père-Charles-de-Foucauld, 14000 Caen, France 

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Résumé

Les malades psychiatriques, à l’instar de leurs soignants, croient peu en leurs capacités de changement face à leur tabagisme. Cela est dû en partie à la dépendance souvent sévère de ces sujets, mais aussi à une composante culturelle et cognitive partagée : la maladie psychiatrique empêche tout espoir d’arrêter de fumer. L’approche groupale mixte, utilisant, d’une part, les principes des thérapies cognitivo-comportementales, notamment la mise en lumière de distorsions cognitives qui bloquent la démarche de changement et, d’autre part, ceux de l’approche motivationnelle, montre que ces personnes ont les mêmes dispositions d’introspection et de fonctionnement en groupe que les non-malades. Il semble que l’impact de l’approche soit double, fait d’une forte mobilisation vers le soin au décours des séances groupales (90 %), et d’une réussite en termes de changement pour ceux qui ont fait la démarche individuelle. Ce résultat repose aussi sur l’implication institutionnelle ayant encouragé et soutenu les patients, et la continuité des thérapeutes, les sujets ayant retrouvé dans le soin les professionnels, animateurs des séances en groupe.

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Summary

Smokers with psychiatric problems consume more tobacco and have higher dependency levels than the general population (Office français de prévention du tabagisme [OFT] et Fédération française de psychiatrie, 2009 [1]; Wiesbeck et al., 2008 [2]; Ostacher et al., 2006 [3]; Quattrocki et al., 2000 [4]; Glassman, 1993 [5]; Dervaux et al., 2004 [6]; OFDT, 2006 [7]; Lasser et al., 2000 [8]; Grant et al., 2004 [9]; Williams et al., 2005[10]). They rarely seek help to stop smoking (Fagerström et al., 2009[15]; Ratschen et al., 2009 [16]). However, the OFT and the French Anti-Tobacco Association, 2009 [1] recommend smoking cessation with the help of a psychiatrist, outside of severe episodes, nicotine replacement therapy and cognitive-behavioral therapy (CBT). CBT aims to reduce self-destructive behaviors and excessive emotional reactions by modifying dysfunctional or erroneous thoughts and maladaptive beliefs which underlie these reactions (Ellis, 1962 [19]; Beck et al.,1976 [20]; Beck et al.,1979 [21]; Mahoney 1991 [22]; Cottraux, 2011 [23]). As dependant patients are often ambivalent about their interest in change (Beck et al., 1993 [27]; Bishop, 2000 [28]), the therapist has to act specifically on factors influencing motivation. A therapeutic relationship and quality intervention strategies are favored (Cungi, 2006 [33]; Miller and Rollnick, 1991 [34]; Miller et al., 1993 [35]; Miller, 2000 [36]; Project Match Research Group, 1997 [38]). Motivational interviewig (MI) was specifically developed with this in mind (Miller et al., 1991 [34]). To help patients who smoke overcome their ambivalence and commit to change, it is possible to work on motivation in a group context (Ingersoll et al., 2000 [39]). For this purpose, we formed the tobacco awareness group (TAG) at the interface of CBT and MI. The objective was not abstinence but the creation of a place of exchange, understanding, formation of hypotheses and experimentation on reduction in smoking.

The TAG in a sheltered workshop

Our hypothesis was that participation in a TAG could modify the beliefs of smokers with psychiatric problems and encourage them to commit to change. Our experiment took place in a sheltered workshop for people with a treated and stabilized mental disorder. It was a closed group of six sessions from 1h30mins to 2h (one day a week) led by two therapists (a doctor specialized in smoking cessation and a psychologist trained in CBT). The group was made up of 10 people: a facilitator without a mental disorder and nine workers at a sheltered workshop of which 50% had strong dependence and 50% average dependence. They were all ambivalent towards change.

Analysis and results

Participation in the TAG brought up certain reoccurring cognitive distortions shared by all members in the group. On the one hand, dogmatic demands with regard to change: abstinence as the sole objective, absence of mental disorder before being able to stop and the need to stop without any assistance. On the other hand, cognitions showing low tolerance to frustration in emotionally uncomfortable situations. Initially ambivalent, 90% of patients took individual action following the TAG to try to modify their consumption. They wanted to consult the therapists who had led the TAG. They all tried to reduce consumption using nicotine patches and 60% tried to give up completely. One of these people managed to do so for more than a year. Although this population is traditionally considered to be difficult, participants remained committed. The impact of the TAG on the process of change over one year is analysed in relation with involved factors.

Discussion

The diversity of the TAG approach seems effective. The group dimension is highly recommended for this type of population who benefit from social support. It is primordial that abstention is not the only objective. The main originality of this TAG was the identification of a specific belief that psychiatric disorders prevent smoking cessation. The comments of all participants seem to confirm the underlying dogma of self-medication (Strand and Nybäck, 2005) [11]: they smoke to control their emotions, their moods, which are, in their opinion, caused by their disorder. Bringing this dogma to the level of a hypothesis allowed the group to explore other ways of confronting situations in daily life without smoking. This action could not have been successful without the work of the professionals at the sheltered workshop who accompanied and supported the participants at key moments of stress (first session of the TAG, individual consultation). Once the participants were committed, they came on their own.

Conclusion

This TAG seems to have contributed in modifying certain beliefs and encouraging a commitment to treatment. Support by the institution is essential in creating and maintaining group dynamics, and supporting individual initiatives.

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Mots clés : Thérapie cognitive comportementale, Groupe psychothérapeutique, Motivation, Tabac, Malades psychiatriques

Keyword : Cognitive behavior therapy, Group psychotherapy, Motivation, Tobacco, Psychiatric patients


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© 2013  Publicado por Elsevier Masson SAS.
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