ror.org/02xrw9r68
Abstracts
Résumé
Malgré une vaste littérature sur l’abandon de traitement en pédopsychiatrie, les connaissances sur cette problématique chez l’adolescent avec trouble de personnalité limite (TPL) demeurent peu développées. Les conséquences d’un arrêt prématuré du traitement sont sérieuses considérant la récurrence de leurs conduites suicidaires. Afin de comprendre les processus associés à l’instabilité du mode de consultation de ces adolescents, une méthode de théorisation ancrée constructiviste avec un devis de cas multiples a été utilisée. Trente-quatre entrevues auprès de trois groupes d’informateurs (adolescent, parent et clinicien) ont été réalisées. Un modèle explicatif des facteurs de risque d’abandon, mais aussi des conditions susceptibles de favoriser la poursuite du traitement a été élaboré. Il identifie les déterminants de l’abandon qui sont spécifiques aux adolescents avec TPL et décrit les processus par lesquels ceux-ci interfèrent avec la poursuite du traitement. Deux moments critiques ont été mis en évidence. Le premier survient au moment de l’offre de traitement. Il est déterminé par les capacités du dispositif de soins à profiter de l’impulsion de la demande d’aide pour engager l’adolescent et le parent en tenant compte de leurs vulnérabilités à l’abandon. Le deuxième moment critique survient en cours de traitement. Il est marqué par les capacités du dispositif de soins à adopter des mesures correctives lorsqu’apparaissent des complications d’engagement. Ces résultats mettent en évidence l’importance des réponses du dispositif de soins et suggèrent que l’engagement des adolescents avec TPL devrait constituer un objectif thérapeutique au même titre que la réduction de la symptomatologie et des problèmes de vie.
Mots-clés :
- abandon de traitement,
- trouble de personnalité limite,
- adolescent,
- engagement,
- recherche qualitative
Abstract
Objectives More than half of suicidal adolescents, a large proportion of which manifest borderline personality disorder (BPD), drop out from treatment. The consequences of their premature termination are cause for concern given the recurrence of their suicidal attempts and that they present elevated risk for major mental disorders during adulthood. The study sought to gain a broader appreciation of processes involved in the treatment dropout among adolescents with BPD.
Method A constructivist grounded theory was chosen using a multiple-case research design. Twelve cases were examined. Three groups of informants were recruited (adolescents, parents, and therapists involved in the treatment) and 34 interviews were conducted to document the cases. Theoretical sampling and the different stages of analysis specific to grounded theory were performed according to the iterative process of constant comparative analysis.
Results Various dropout vulnerabilities specific to adolescents with BPD and their parents, including psychological characteristics, help-seeking context and perception of mental illness and mental healthcare were identified. Care-setting response including management of accessibility problems, adaptation of services to needs of adolescents with BPD, preparation for treatment, and consideration for the health professional’s disposition to treat were also found to be determinant to their engagement to treatment. The processes of disengagement from treatment have also been specified. Negative perceptions regarding treatment, clinicians and receiving treatment have been shown to generate emotional activation. The aforementioned lead to counterproductive attitudes that evolve into outright disengagement behaviours. In this context, responses from the care-setting, such as an insufficient regulation of the engagement, therapeutic faux pas and paradoxical demands, precipitate premature treatment termination. Finally, the processes involved in the abandonment of treatment were formalized in the Model of engagement and treatment dropout for adolescent with BPD. This theoretical model highlights two key milestones that may lead to treatment completion or to dropout during care. It illustrates that distinct processes characterize the premature and late dropouts of adolescents with BPD. The early terminations result from the failure of the care-setting to take advantage of the impetus for help seeking to engage the adolescent and the parent at that first critical moment in the care trajectory. On the other hand, the late dropouts translate failures of the care-setting to adopt corrective measures to maintain the patient in treatment at a second critical moment indicated by their disengagement.
Conclusion The termination rate of those adolescent treatments could be diminished by a system of care-setting that recognizes the inherent difficulties related to the treatment of those specific patients, is proactive to solve problems of disengagement, integrates support systems for clinicians and promotes a reflexive practice.
Keywords:
- treatment dropout,
- borderline personality disorder,
- adolescent,
- engagement,
- disengagement,
- care-setting,
- suicidal behaviour,
- qualitative research
Appendices
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