Effet d'un programme d'entraînement des habiletés sociales chez un patient souffrant de schizophrénie : un cas clinique

Understanding schizophrenia is grounded in the stress - vulnerability - adaptive competence explanatory model [1], which requires multidimensional therapy, such as that promoted by psychosocial rehabilitation. We now know that poor social skills are a vulnerability factor, which not only aggravate patients' symptoms but also undermine their inclusion in daily life. Patients with schizophrenia, who have troubled relationships with themselves and others, have a tendency for social withdrawal and avoidance linked to certain delusions, in particular, persecution. In this context, social skills training together with drug therapy, family and social support, psychoeducation and cognitive remediation are all protective factors against relapse [6-8]. The basic principles of these interventions are an integral part of the psychosocial rehabilitation programs inspired by cognitive-behavioral therapy. Various studies have shown the efficiency of this therapy in reducing psychotic symptoms and improving self-esteem, quality of life or social adjustment of patients with schizophrenia [9-11]. The case study presented in this article shows the development of a program offered in a social health care centre aimed at the socio-professional integration of people with psychiatric disorders. The therapeutic approach is part of multidisciplinary treatment based on a neuropsychological and cognitive-behavioral approach. This case was interesting because the program took place in a non-health centre where cognitive-behavioral therapy, which is not widely used with patients with psychotic problems, has a place and produces positive results in the improvement of the patient's social behavior. The patient was a young, 21-year-old man with schizophrenia. At the start of the program he was being treated by a psychiatrist in his local psychiatric unit. He lived with his mother. He wanted to train to become a baker in a vocational training centre. His main complaint was social withdrawal linked to ideas of persecution following a first hospitalization for a brief psychotic disorder. The patient avoided many social situations. According to the initial clinical evaluations, the patient showed low self-esteem, severe social phobia and poor social adaptation. The delusions were well-controlled by medication and the patient had good insight. The program offered social skills training using the game “Competence” [40], self-assertiveness sessions adapted for schizophrenia, relaxation exercises, cognitive retraining in environmental conditions, interspersed with individual therapy sessions. At the end of the program, which lasted 6 months, we noticed that, in the case of this patient, social skills training had led to a reduction in social anxiety, improved assertiveness and a reduction in social withdrawal linked to a mitigation of the presence of “persecuting looks” in everyday life. We also noticed an improvement in attention abilities of the patient, which could be linked to a decrease in anxious expectations. However, due to the intense relationship with his mother, the patient maintained erroneous beliefs about his professional capabilities and refused a place in a sheltered workshop, which better suited his current overall cognitive abilities. The failure of his career plans showed the importance of working with families. As the length of the program was limited, communication and partnership with the patient's local health team was extremely important to maintain his progress. These different elements show the importance of a multidimensional, integrated, networked approach in the support of patients suffering from psychotic disorders.