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Université Du Québec À Chicoutimi Mémoire UNIVERSITÉ DU QUÉBEC À CHICOUTIMI MÉMOIRE PRÉSENTÉ À L’UNIVERSITÉ DU QUÉBEC À CHICOUTIMI COMME EXIGENCE PARTIELLE DE LA MAÎTRISE EN TRAVAIL SOCIAL PAR ALEXANDRE THÉBERGE LES FACTEURS D’INFLUENCE DANS LE RÉTABLISSEMENT DES PERSONNES ATTEINTES D’UN TROUBLE CONCOMITANT : UNE ÉTUDE EXPLORATOIRE AOÛT 2017 ii Sommaire Les troubles mentaux graves sont à l’origine de grandes souffrances humaines ce qui a pour effet d’altérer le fonctionnement social des individus et entrainer une forte utilisation de soins spécialisés gouvernementaux. Au Québec, le Ministère de la Santé et des Services sociaux (MSSS, 2005) dans son plan d’action en santé mentale affirme que de 2 à 3% de la population adulte souffre d’un trouble mental. Toutefois, on observe rarement la présence d'un seul diagnostic de TMG. En effet, les personnes atteintes d’un trouble mental grave risquent davantage d’avoir une problématique reliée à la consommation de substances et vice-versa (Skinner, O'Grady, Bartha, & Parker, 2004). Le plan d’action en santé mentale du MSSS (2005) a aussi démontré une forte corrélation entre ces deux problématiques. Jusqu’à deux tiers des personnes ayant un trouble mental au Québec auraient aussi une problématique de consommation de substances. Cette concomitance engendre de nombreuses complications dans la prise en charge de ces individus soit : une plus grande fréquence d’hospitalisation (Haywood et al., 1995), plus de rechutes (Landry, Cournoyer, Bergeron, & Brochu, 2001; Schmidt, Hesse, & Lykke, 2011; Swofford, Kasckow, Scheller-Gilkey, & Inderbitzin, 1996; Xie, McHugo, Fox, & Drake, 2005), davantage de probabilités de vivre des conditions de pauvreté (Caton et al., 1994; Drake et al., 1991; McGinty, Baker, Steinwachs, & Daumit, 2013; Schmidt et al., 2011), une satisfaction moins élevée dans les relations familiales (Dixon, McNary, & Lehman, 1995) ainsi que des risques plus élevés dans le domaine des infections transmissibles sexuellement et par le sang tel que l’hépatite C et le VIH/Sida (Rosenberg et al., 2001). Malgré tout, de nombreuses personnes ayant un trouble mental grave sont en mesure d’améliorer leur qualité de vie et d’apprendre à vivre avec ladite maladie sans consommation problématique. Le processus de rétablissement de ces personnes constitue l’objet de cette étude. Plus précisément, leur vision de ce que représente le rétablissement, les facteurs positifs, négatifs et ceux impliqués à long terme en lien avec leur cheminement de mieux-être sont aussi des éléments abordés dans la présente recherche. Cette étude a permis de mieux comprendre le phénomène du rétablissement auprès des personnes présentant un trouble concomitant selon une approche bioécologique. Les participants de cette étude ont tous été recrutés à l’Institut universitaire en santé mentale de Québec. Plusieurs constats liés aux facteurs influençant le rétablissement émergent de cette étude : a) il y a une hétérogénéité de facteurs individuels et une homogénéité de facteurs environnementaux et liés aux interventions, b) le soutien social et les activités significatives sont des facteurs déterminants dans le processus, c) plusieurs facteurs, peuvent avoir à la fois une influence positive ou négative et d) il y a des interactions constantes entre le trouble mental et le trouble lié à l’usage de substances sur le rétablissement. Sans toutefois pouvoir généraliser à l'ensemble de la population, les facteurs évoqués permettent de mieux saisir les enjeux du rétablissement, mais également d’orienter les équipes de traitement en trouble concomitants et leurs interventions. iii Table des matières Introduction .................................................................................................................................... 1 Chapitre 1 : Problématique à l’étude .............................................................................................. 6 1.1 L’ampleur des troubles mentaux dans la société ............................................................ 7 1.2 L’ampleur des troubles concomitants dans la société .................................................... 9 1.3 Les facteurs de risques et les répercussions de la concomitance ................................. 11 Chapitre 2 : recension des écrits .................................................................................................. 16 2.1 Les troubles concomitants ............................................................................................ 17 2.2 Le rétablissement d’un trouble mental ......................................................................... 23 2.2.1 Les facteurs liés au rétablissement d’un trouble mental ............................................. 27 2.3 Le rétablissement d’un trouble lié à l’utilisation d’une substance ............................... 38 2.3.1 Les facteurs liés au rétablissement d’un trouble lié à l’utilisation de substance ......... 41 2.4 Le traitement intégré pour les personnes ayant un trouble concomitant ............................ 54 Source : Traduction de Drake et al. (1998), p. 3. ................................................................. 60 2.4.1 L’efficacité du traitement intégré pour les personnes ayant un trouble concomitant . 60 2.5 Limites des études consultées ............................................................................................ 67 2.6 Pertinence de la recherche.................................................................................................. 69 Chapitre 3 : Cadre conceptuel ...................................................................................................... 71 3.1 L’approche bioécologique et ses fondements .................................................................... 72 3.2 Le modèle transthéorique du changement ......................................................................... 77 3.3 Modèle exploratoire des facteurs qui influencent le rétablissement des personnes ayant des troubles concomitants ........................................................................................................ 82 Chapitre 4 : Méthodologie de la recherche .................................................................................. 85 4.1 Type d’étude ...................................................................................................................... 86 4.2 Les principaux objectifs de la recherche ............................................................................ 87 4.3 Population à l’étude ........................................................................................................... 88 4.4 Méthode d’échantillonnage et recrutement ........................................................................ 89 4.5 La collecte de données ....................................................................................................... 92 4.5.1 La fiche signalétique ................................................................................................... 93 4.5.2 Le Stages of Recovery Instruments (STORI) ............................................................. 94 4.5.3 Le University of Rhode Island Assessment Scale (URICA)....................................... 95 4.5.4 L’entrevue semi-dirigée .............................................................................................. 97 4.6 L’analyse des données ....................................................................................................... 97 4.7 Les considérations éthiques ............................................................................................. 100 Chapitre 5 Présentation des résultats ......................................................................................... 102 iv 5.1 Le profil des répondants ................................................................................................... 103 5.1.1 Profil sociodémographique des répondants .............................................................. 103 5.1.2 Profil de consommation de substances psychoactives des répondants ..................... 105 5.1.3 Profil d’utilisation des services en santé mentale des répondants ............................. 109 5.2 L’apparition, l’évolution et le rétablissement d’un trouble mental .................................. 111 5.2.1 L’apparition du trouble mental ................................................................................. 111 5.2.2 Vivre au quotidien avec un TM ................................................................................ 115 5.2.3 L’évolution du TM dans la dernière année et les facteurs associés .......................... 117 5.2.4 Le rétablissement du trouble mental et ses facteurs d’influence ............................... 119 5.2.4.1 Perception des répondants face à leur rétablissement .......................... 119 5.2.4.2 Perception des répondants face aux facteurs d’influence dans leur rétablissement .................................................................................................... 121 5.3 L’apparition, l’évolution et le rétablissement d’une problématique de consommation ........................................................................................................................ 125 5.3.1 Le premier contact avec les substances ..................................................................... 126 5.3.2 Les avantages et les désavantages de la consommation ............................................ 129 5.3.3 Le rétablissement de la problématique de consommation .......................................
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