L'objectif de ce travail est d'evaluer les effets d'une prise en charge psychologique specialisee pour des sujets souffrant d'etat de stress post-traumatique. La population est constituee des 20 premiers patients (moyenne d'age = 43 ans) de cette consultation, victimes de divers evenements traumatiques (8 agressions physiques et 12 accidents). Les criteres retenus dans l'evaluation du changement therapeutique ont ete : a) l'amelioration des symptomes psychotraumatiques (criteres DSM-IV) ; b) l'amelioration de la sante mentale globale ; c) l'estimation du changement par le therapeute et par le patient ; d) la qualite de l'alliance therapeutique. Les sujets ont ete evalues au debut de la psychotherapie et trois mois et demi apres, a l'aide de questionnaires d'auto-evaluation et d'hetero-evaluation (Criteres DSM-IV de L'etat de stress post-traumatique, l'Inventaire d'Etat de Stress Post-traumatique de Steinitz et Crocq (1992), l'Echelle d'Auto-Evaluation des Etats de Stress Post-traumatique de L. Crocq (1990), l'echelle de Sante-Maladie de Luborsky, le Questionnaire d'Alliance Aidante (Penn Helping Alliance Questionnaire Method)) (Alexander et Luborsky, 1986). Les resultats montrent que, trois mois et demi apres la psychotherapie, 16 sujets sur 20 se sont nettement ameliores alors que quatre sujets presentent encore des troubles psychotraumatiques associes a des troubles depressifs et somatiques. L'amelioration symptomatique s'accompagne toujours d'un mieux-etre sur le plan de la sante mentale generale des sujets, qui parviennent a reinvestir le champ social et relationnel. L'etude montre aussi que le changement positif est lie aux deux dimensions de l'alliance aidante (alliance de travail avec les therapeutes et sentiment d'avoir ete compris et soutenu) et aux capacites d'autonomie des sujets. L'etude indique egalement que les sujets qui ont beneficie d'une prise en charge precoce s'ameliorent plus rapidement que ceux dont les soins ont ete plus tardifs apres l'evenement traumatique. Malgre l'interet des resultats, cette etude comporte quelques limites methodologiques : therapeutes impliques dans l'evaluation et faible recul temporel (trois mois et demi apres psychotherapie) lequel ne permet pas de conclure forcement a une amelioration durable ni de juger des eventuelles rechutes.
There are currently a large number of results published in English concerning the question of evaluating the therapeutic care of posttraumatic stress states, in particular since their international recognition by the DSM in 1980. Overall, the studies reveal no difference in effectiveness between various recognized therapeutic methods while cognitive therapies seem to lead to even better results. Operating within the framework of emergency psycho-medical units, we have set up a consultation facility specializing in the psychological treatment of posttraumatic stress states intended for individuals who do not suffer from serious personality disorders or any major associated psychiatric problems. The technical aspects of this psychological consultation take their inspiration from the psychodynamically-based model of short term psychotherapy. This consultation is accompanied by medical and social care given by a psychiatrist who is responsible for prescribing the treatment and for relations with the social, professional and possibly also legal institutions. The aim of this study was to evaluate the effects of this specific care on the improvement of the psychotraumatic symptoms and the general health of these patients. The population consisted of 20 initial patients (mean age = 43 years) who had been the victims of a variety of traumatic events (eight physical assaults and 12 accidents). The criteria used for the evaluation of the clinical change were: (a) symptomatic criteria relating to the improvement of the posttraumatic symptoms (DSM-IV criteria); (b) criteria relating to the improvement in general mental health; (c) criteria relating to the evaluation of the change by the therapist and the patient; (d) criteria relating to the evaluation of the psychotherapy taking account of the notion of therapeutic alliance. The subjects were assessed at the end of the psychotherapy and then again three and a half months later. Both self-evaluation and external evaluation questionnaires were used (DSM-IV criteria for the posttraumatic stress state, the Steinitz and Crocq posttraumatic stress state inventory (1992), L. Crocq's posttraumatic stress state self-evaluation scale (1990), Luborsky's health-sickness scale, the Penn Helping Alliance Questionnaire Method (Alexander and Luborsky, 1986). The results showed that only four of the 20 subjects still exhibited a posttraumatic stress state three and a half months after the therapy. These non-improving subjects also suffered from associated pathologies (major depression and somatization), a conflictual problem that predated the trauma and numerous problems at the social level. Furthermore, in the patients who did exhibit an improvement, the ''alertness state'' concerning those cues that risked provoking recall of the trauma continued to be of moderate intensity. The improvement in the symptoms was accompanied by a general improvement in the mental health of the subjects who were able to reinvest in their social lives and relations. The study, therefore, shows that the subjects' improvement is correlated with two dimensions of the helping alliance method (working alliance with therapists and feeling of having been understood and supported) and the subjects' capability of acting independently. Finally, the speed with which psychological care is initiated following the traumatic event seems to be a determining factor for patient improvement: the earlier care is administered, the faster subjects are able to regain their balance. The proposed evaluation is subject to a certain number of limits: therapists involved in the evaluation and the brief evaluation interval (three and a half months after the psychotherapy) which does not necessarily allow us to conclude that the improvement is permanent or assess possible relapses.