Reprendre le chemin des soins après la mort accidentelle d’un thérapeute : quelle articulation des soignants et des patients ?

Résumé La problématique du deuil normal ou pathologique fait l’objet d’une multitude de publications. Au sein de cette pléthore éditoriale, un seul sujet manque à l’appel : le psychothérapeute lui-même, pourtant instigateur de ces études. La mort du thérapeute viendra interroger le patient sur le sens de la vie, le réel de la mort, la possibilité d’obtenir un socle de soutien durable. Une relation thérapeutique qui s’établit depuis de nombreuses années et au sein de laquelle le praticien a été l’archiviste et le dépositaire des secrets les plus intimes ne peut s’interrompre brutalement sans souffrance. Le deuil du thérapeute peut être « compliqué » c’est-à-dire inhabituel, avec une souffrance marquée et persistante. Le deuil peut aussi être « pathologique », avec le déclenchement d’une pathologie physique ou mentale, par définition absente avant le décès mais classiquement retenue a posteriori comme latente et témoignant d’une vulnérabilité préalable, vulnérabilité pour laquelle le sujet avait peut-être engagé une thérapie. Les patients devront être reçus individuellement et rapidement pour l’annonce du décès. Cette annonce permettra une évaluation du tableau psychopathologique latent et des défenses psychiques qui pourraient être opérantes. Dans tous les cas, un second rendez-vous sera proposé et une invitation à un groupe de parole remise. Une question cardinale est de savoir si les patients peuvent se rendre aux obsèques de leur thérapeute. Nous partageons cette idée car elle limite la capacité de déni et demeure un rite social opérant qui canalise les passions. Également, la possibilité d’un groupe de parole joignant patients et soignants permettra de partager ces craintes et de dissiper les malentendus. À l’échelon individuel, la poursuite de la psychothérapie intégrera nécessairement cet événement récent de confrontation à la possibilité de la mort. L’événement traumatogène du deuil pourra être en lui-même réinscrit dans la trajectoire du sujet via une perspective thérapeutique qui permettra de « faire son deuil » et de poursuivre les soins déjà engagés. Alors que la mort brutale de son thérapeute a fréquemment été vécue dans une absence du dire, l’acceptation de la fatalité et du néant s’établira sur une production du sujet. Introduction The world of medicine, hospitals, is in close contact with and is interested in death; many practitioners deny it and attempt to avert it themselves. Much research deals with the reaction of patients in the face of their own death or that of a family member or a friend. The problem of normal and pathological bereavement has been the subject of numerous publications. Within this editorial superabundance, one subject is missing: the psychotherapist, often the instigator of these studies. The death of the therapist, sudden or expected, is a difficult issue for their patients as well as their colleagues and certainly for the therapist themselves. This death, always sudden, will surely lead the patient to question the meaning of life, the reality of death, the possibility of obtaining lasting support. This question of denial of the death of the aging and ill psychiatrist is undoubtedly ingrained in the history of the father of psychoanalysis who, suffering from a particularly painful post-smoking neoplasia, continued to smoke and see his patients until the day he died. Let us suppose that the psychiatrist had an unconscious mind; within it he may therefore be persuaded of the absence of possibility of his own death and live in the present of immortality. It is thus how Freud lived, like everybody he thought. Thus, structural elements of the analytical treatment increase this feeling of immortality. Clinical findings A therapeutic relationship established over several years and for which the practitioner was the archivist and the guardian of the most intimate secrets, to prepare a better future, cannot be interrupted suddenly without suffering. The mourning of the therapist can be complicated that is to say unusual with a marked and persistent suffering; or pathological triggering a physical or mental pathology by definition absent before the death but traditionally retained afterwards as latent and evidence of a prior vulnerability, vulnerability for which the subject had undertaken the therapy. The risk of anaclitic depression or even melancholic breakdown is to be feared. A psychotic decompensation can occur in the face of bereavement and when the secondary treatments are stopped lead to a medical escheatment. Acting out suicide or self-harm can bring into question the relationship between the therapist and the patient through the spectrum of pain and death. Of course the reaction of the subject can be strictly foreseeable due to the inter-subjective relationship uniting the protagonists. How can the patient therefore move on to another therapist and will this procedure necessarily be therapeutic? Guidelines A non psychotraumatic announcement must be made to the patients to pre-empt a fortuitous discovery via another patient or the press, which requires good reactivity on the part of the medical team. The patients must be seen individually quite quickly to announce the death in person. It is a good idea for the patient to be seen by a doctor they already know, for example having met them when their referring therapist was absent. This announcement will enable an evaluation of the latent psychopathological picture and the psychic defences, which may or not be operative. The follow-up will depend on each clinical situation after looking very carefully at the anamnesis, detailing the psychiatric examination and evaluating the patient's reaction to the announcement of the tragedy. In any case, a second appointment will be proposed and the subject will be invited to join a therapy group. A cardinal question is to know if the patients can go to their therapist's funeral. We share this idea as it limits the capacity of denial and remains an operative social ritual which channels emotions. This event should be managed by the medical team and will retain a therapeutic value. Also, the possibility of group therapy bringing together patients and medical staff will enable them to share their fears and dispel any misunder [ABSTRACT FROM AUTHOR]