L’hospitalisation en psychiatrie : point de vue des patients et perspectives éthiques

RésuméL’assimilation de plus en plus fréquente de l’hospitalisation en psychiatrie à l’enfermement nécessite une réflexion sur la portée de cette modalité de soin. L’objectif de ce travail est d’explorer le vécu et la perception des effets de cette expérience au regard d’une perspective éthique. L’étude était fondée sur une enquête par questionnaire réalisée auprès de 169 patients au terme de leur séjour hospitalier. Une analyse statistique descriptive a été réalisée avec le logiciel SPSS 17.0 et les résultats examinés au filtre des principes éthiques fondamentaux (autonomie, bienfaisance, non-malfaisance). Elle a mis en évidence que l’autonomisation est favorisée par l’existence de repères dans le déroulement des soins (plus de 85 %), la liberté de circulation (82 %), l’information sur le projet thérapeutique (83 %), et remise en cause surtout en matière d’implication dans l’orientation des soins et d’information sur le mode d’hospitalisation (67 %) et la maladie (71 %). La bienfaisance est respectée tant au niveau de la disponibilité des soignants (94 %) que des effets bénéfiques reconnus et de l’utilité (90 %). Cependant, l’hospitalisation est une expérience potentiellement chargée d’affects négatifs (vécu pénible 50 %, impuissance 40 %) qui pourraient être atténués par une écoute plus active, ainsi qu’une information et une responsabilisation accrues des personnes hospitalisées.

BackgroundPsychiatric practice is often faced with complex situations that pose serious moral dilemmas for mental health professionals. To some degree, all mental health professionals limit autonomous decision making on a person already impaired by illness. Ethical considerations become more complex when involuntary hospitalization or coercive measures serve to restore autonomy in patients with temporary mental incapacity. The ethical debate around involuntary hospitalization or coercive measures, and more globally around psychiatric care is concerned with whether deprivation of liberty can really be justified in order to help a patient regain his autonomy. On the other hand, patients’ opinions and views are increasingly being recognized as major indicators of how well health services and health systems are performing, as well as providing guidance for further service improvement. Little is known about the patients’ views of admissions to psychiatric hospitals from an ethical perspective.ObjectiveThe objective of our study, which is a part of a research project on the ethical references in institutional psychiatric practices is two-fold: To explore the experiences of hospitalized patients, and their perception of the effects of the hospitalization on their suffering and on restoring their psychological autonomy, then to offer possible ways to improve hospital care with a view to an ethical perspective. In this article, the principles based approach to biomedical ethics developed by Beauchamp and Childress is used, with a particular focus on autonomy, beneficence, and non-maleficence.MethodThe study was conducted in April and May 2010 in full-time hospital units in ten general psychiatry sectors at three hospital sites in Marseille. The study was based on a survey by questionnaire conducted with patients at the end of their hospital stay. The questionnaire consisting of 64 items sought to explore their viewpoints with respect to ethical principles: autonomy (free-will or agency), beneficence (to do good), non-maleficence (not to harm). A descriptive statistical analysis was conducted with SPSS 17.0 software. Data are presented as proportions for discrete variables and as means ± standard deviations for continuous variables.ResultsAmong the 183 patients identified to participate in the survey, 14 refused. A total of 169 patients participated in the study. It showed that empowerment is promoted by the existence of milestones in treatment (more than 85%), freedom of movement (82%), information about the therapeutic plan (83%) and raising questions, especially about involvement in the direction of treatment (58%) and information about the mode of hospitalization (67%), the illness (71%) and the effects of medications (71%). Beneficence is respected at the level of availability of care providers (94%) as well as at the level of recognized beneficial and utilitarian effects (90%). However, hospitalization is an experience potentially loaded with negative affects (experienced as painful 50%, powerless 40%, fear 33%), even if it had protective effects in relation to one's self (86%) and others (53%) and is considered justified (87%).ConclusionIn this study, the viewpoint of patients shows that the majority have a favorable perception of the hospital stay and the effects of the stay. These results suggest that attention must be paid to various information delivered during the stay and to the participation and empowerment of patients. This process would move in the direction of more active listening and greater autonomy, and could alleviate feelings of powerlessness, devaluation and the experience of the stay as a punishment. Thus, the process could have a positive impact on the relationship and acceptance of treatment in the future. Treatment teams could have an analytical tool in the form of a patient questionnaire, which would make it possible to approach the manner in which the arrangement of the proposed therapeutic process is perceived with the objective to adapt practice to a therapeutic and ethical intent. An important future research project would be an examination of whether following patients’ preferences using our questionnaire results in a better perception and a less aversive experience.