[Patient and their relatives' satisfaction regarding a home-based crisis intervention provided by a mobile crisis team]. / Evaluation de la satisfaction des patients et de leurs proches vis-à-vis d'une prise en charge de crise ambulatoire par un service mobile d'urgence et de post-urgence psychiatrique.

The goal of this survey was to evaluate the patients and their relatives' satisfaction with a home-based crisis intervention provided by a psychiatric mobile crisis team (Equipe Rapide d'Intervention de Crise, hôpital Charcot, Plaisir). We were particularly interested in measuring satisfaction with telephone response time, team mobility, patient welcome, family consultations, information given to patients and the number of caregivers. We designed a questionnaire that included 24 closed questions and 2 open-ended questions. Replies were collected over the telephone by an outside psychologist with no prior knowledge of the patients. The inclusion criteria were the following: the patient had to have received a home-based crisis intervention from the mobile crisis team and to have received at least two follow-up consultations. The response rate was 95%, from 81 relatives and 73 patients. The results show a high level of overall satisfaction, with satisfaction levels at over 90% for some of the questions. High satisfaction was due to the human and professional approach of staff - their listening skills and competence - the 24-hour availability of the telephone service, the fast intervention of the team, the team mobility, and the systematic involvement of relatives as part of the program. Low satisfaction was due to the high number of caregivers, the short length of programs, the patient referral process to outpatient services, the lack of information on medication and patients' illness and the sad appearance of the building. These results lead us to improve some aspects of our service or at least to explain our services more fully to clients. More generally, these results encourage us to listen more attentively to patients' opinions on how they experience their psychiatric care.

[Posttraumatic stress state: a therapeutic lever]. / Etat de stress post-traumatique: un levier thérapeutique.

Chronic post-traumatic stress disorder (PTSD) is a very complex syndrome which is hard to detect because of the multiplicity of its expressions. Further more, these clinical expressions are far from the "pure" syndrome described in the DSM IV. So, the clinician faces a dilemma: how can he account for the traumatic clues without using the PTSD as a ragbag of a diagnosis? We found the way to discard this dilemma when we decided to use what M. Struber said about her experience with cancer and PTSD. She suggests not to emphasize psychopathology and to use a post-traumatic stress framework. This way to reframe some psychiatric urgencies is very useful because it gives back ability to the patient. When using a post-traumatic stress framework we tell the patient and his family that we acknowledge he has defensible reasons for not managing with an event which, we acknowledge too, was traumatic for him. In that way we begin to explore what each person is experiencing, because the traumatic experiencing is generally shared by the patient and his family. The members of the family are often angry and fed up of the patient behaviour and think themselves as victims of him. On the other part, the patient feels himself as a misunderstood person, victim of the others. The primary trauma is forgotten for a long time or nobody make any link between it and what is happening in the present. The manifestations of the PTSD initiate subsequent aftermaths and suffering for everybody. When working with psychiatric emergencies, we have to manage with acute situations in which each people is both victim and aggressor and in which clinicians run the risk of being given the role of either victim or aggressor. The trial of strength played between the patient and his family is going to be played with the clinician. These situations are described by S. Lamarre when she speaks of "victimisation" and are overloaded with control stake. Each one tries to make the other guilty and disgraced, and the clinician is at risk to feel and/or make feel in the same way the patient and his family. These situations are blocked and the temptation is to resort to a kind of coup when the clinician decides it's enough! and forces his opinion and decision. What is not a very good way to create the essential therapeutic co-operation! In this article we show how using a post-traumatic stress framework is very useful to reframe the situation of "victimisation", give the opportunity to discard its trap, open a new sight which allows to find new solutions and promote a therapeutic co-operation. It's important to stress the fact that it's not efficient to use a post-traumatic stress framework as a formula. The clinician who uses it has to feel it, otherwise he will be unable to co-create this new reality with the system he entered, when receiving the emergency.

[Post-traumatic stress disorder (PTSD): the syndrome with multiple faces]. / Etat de stress post-traumatique: le syndrome aux différents visages.

We choose to discuss from the PTSD's point of view because this diagnostic reference is commonly used. We wish outline its restrictive sight which could prevent the professional from having a diagnosis of PTSD. We don't want to say there is a PTSD everywhere but it appears to us that a traumatic reading can be a precious advantage for the clinician to establish a real therapeutic relation with some patients. Post-traumatic syndrome differs from the majority of other diagnostic categories as it includes in its criteria the presumptive cause of the trauma (criterion A). In the case that this syndrome originates in war experiences, the presumed cause presents itself as an exceptional event overcoming the individual's resources. The notion of war traumatisation has been extended to other events such as catastrophes, physical attacks, rapes, child and wife battering, and sexual abuses. But the events which cause PTSD (Post-Traumatic Stress Disorder) are significantly more numerous. It can be seen that medical events such as giving birth, miscarriage, heart attack, cancer, or hospitalisation following resuscitation may give rise to PTSD. Further, people experiencing prolonged periods of distress may equally develop a post-traumatic syndrome without any particular event having occurred to surpass their defences. It's the case of the Prolonged Duress Stress Disorder (PDSD). The series of discontinuous stress "waste" the psychic balance and may give rise, at one moment, to posttraumatic symptoms described in DSM, without any specific stressful event. The existence of criterion A is therefore not a necessary prerequisite in establishing a diagnosis of PTSD. It is, in fact, very difficult to predict which events could cause a PTSD, and this, especially, as the subjective aspects count at least as much as the objective aspects. The clinician should have to carefully explore how the patient experienced the event or, how he apprehended the event itself and it's outcome, if he wants get the traumatic range of a life event. The feeling of deep distress, the feeling of being trapped, the loss of control, the collapse of basic beliefs, the feeling that one's life is in jeopardy, that the physical integrity is (really or in one's imagination) threatened, the feeling of helplessness, are quite as much clues for a possible PTSD which hides behind others clinical manifestations either psychological or somatic. Furthermore, the "pure" form described in the DSM and grouping together three further criteria (reliving events, avoiding stimuli associated with the trauma, hyper-reactivity) is extremely rare in the chronic form. An untreated post-traumatic syndrome evolves with time and may present, initially, with very different pathological symptoms giving rise to equally varied diagnoses. Different etiopathogenic models propose to account for the PTSD 's heterogeneous appearance and instability with time. The comorbidity concept sees the PTSD as an independent entity other independent pathologies coexist with. The typologic concept suggests that the PTSD is an independent entity which shows different clinical appearances based on symptomatic descriptions. The "cascade" concept suggests to see the PTSD as an independent entity which offers, with time, different symptomatic appearances, in evolution, because of events caused by after effects, in different areas of the PTSD itself. All of these concepts outline the transnosologic appearance of the PTSD which makes it hardly recognizable. The "chronic" syndrome is rarely diagnosed forming a real challenge to prevention. In effect, the present authors insist on the crucial nature of early detection of PTSD since the greater the time elapsed the more difficult it becomes due to the evolutionary aspect of the syndrome, which initially has more readily recognizable symptoms. The consequences of an unrecognised PTSD are serious and affect both the individual and his immediate family and friends, contributing further to the aggravation of the problems. When a PTSD is diagnosed, it can allow the clinician to further a more global care which will help the patient to get a better recovery. With patients who suffered an infarct, the treatment of PTSD which prevents their recovery will help to go back to the way they lived before the event. It has been showed how important could be the PTSD detection on the severe burned people's pain control. Thus it seems to be crucial for the clinician to keep this diagnosis in mind alongside any other.

[Managing adolescent and adult victims of extra-familial rape soon after aggression]. / Prise en charge des adolescents et des adultes victimes de viols extra-familiaux dans les suites récentes de leur agression.

Rape victims often experience severe and prolonged symptoms in the aftermath of the assault. Psychological assistance offered rapidly after the assault should mitigate the intensity and moderate the duration of rape-related problems. This paper tried to identify the widely-accepted therapeutic approaches from a review of the current literature; it has its roots in the clinical experience acquired by our mobile crisis service in this type of situation, too. The goal of the following practices concerning the victim and the victim's immediate family is to assist the victim to reclaim control as quickly as possible over what has happened and to return to a normal functioning. The therapist should adopt an empathetic attitude, actively and instructively, even more so, and in an even more flexible way than for other patients. Knowledge of one's potential reactions to that kind of situation is useful since the counter-transference is here particularly intense. Doubting the patient's word is part of these negative reactions and must be avoided. It is better to respect the victim's feelings of guilt in the first instance. The relating of the facts, despite its cathartic value, should not be imposed on the patient. It should be noted that these last two points are controversial. It is also important to give information, during interviews, about the symptoms which can occur, the defence mechanisms that the individual sets up for just such occasions and on the most common difficulties encountered in personal relationships. In particular, the therapist must verify that concrete measures are taken to protect the victim against another attack. As far as the immediate family is concerned, it seems particularly important to involve them and, better still, meet them. Their reaction to the rape has a determining influence on the victim's capacity to cope with the trauma and its consequences. On the one hand, the immediate family should be helped in giving support to the victim by telling them all the details of what the patient could suffer, their potential reaction towards the victim and the victim's potential reactions towards them. The question of security must also be brought up with the family, in particular the risk of suicide which can be great. On the other hand, it is important to meet the family to give them support because they too may have difficulty in coming to terms with the violence of the aggression and its consequences. These approaches are up to now the only guidelines available since no psychotherapeutic technique (based on controlled studies) has proved to be more efficient than another and since the clinical experience of the authors are leading them to opposite therapeutic options. Different psychotherapeutic techniques are recommended: short therapies such as cognitive-behavioural therapies or hypnosis, or longer ones such as psychoanalytic psychotherapy. Several of these different options, to which must be added physical techniques like relaxation and medication, are often used simultaneously and/or in succession. As for drug treatments no controlled study conducted with this population has proved their efficiency on post-traumatic stress disorder. According to us they are essentially useful in order to diminish the intensity of the symptoms of anxiety.

[Questionnaire on professional satisfaction with psychiatric emergency services: the professionals' opinion]. / Enquête de satisfaction auprès des utilisateurs d'un service d'urgence psychiatrique: l'avis des professionnels.

Professional's satisfaction concerning medical wards to which they address their patients are scarce, but is part of quality evaluation. The primary care network criticizes often the access to specialized psychiatric cares in emergency. The rapid emergency crisis team (ERIC) is a mobile emergency and post-emergency crisis team depending from public services. It has for purpose to offer early access to specialized care before admission to psychiatric hospital, which general practitioners or other members of social network alert it for a crisis psychiatric situation. The aim of this study was to evaluate the adequacy of ERIC to the needs of professionals, and to improve the collaboration within the network. We performed a mailed study using a questionnaire to 150 general practitioners, 25 private psychiatrists, 7 social circonscriptions, and 5 police departments depending on our intervention's catchment area. Forty-two percent of the professionals answered. Emergency psychiatric crisis situations are scarce, and professional's satisfaction is excellent. ERIC is considered as useful, and the accessibility is underlined. However, information transmitted at the end of the intervention is criticized by the professionals. This study allows to improve some of the procedures and will help to an evolution of our functioning. Moreover, it allows to propose a strategy of prevention oriented to early access to specialized cares.

[Security and home emergency psychiatric interventions]. / Sécurité et interventions psychiatriques à domicile en urgence.

Sectorisation of cares leads professionals to a confrontation with violent home patients. These interventions need a maximal security for professionals. Emergency Mobile Crisis Team (ERIC) has more than 6,000 crisis home interventions' experience. The aim of this study was to assess violent situations during a 42 months experience. We present 70 situations of danger for professionals, and their consequences. Difficulties lead to procedural safety measures, which are presented. Prevention of violence during intervention needs an acute preparation, a clear evaluation of context, and passive or active securisation measures. Occurrence of acting-out is low, but situations considered as dangerous are frequent. We propose some pragmatic issues to increase security in crisis home interventions.