La relation thérapeutique entre l’infirmière et la personne vivant avec un problème de santé mentale en contexte d’autorisation judiciaire de soins

Involuntary treatment orders (ITO) are used in the mental health field to allow for treatment of individuals living with a mental illness considered incapable of giving consent and who are actively refusing treatment. The use of this exceptional measure is increasing around the world, with a presence in 75 different jurisdictions (Rugkåsa et Burns, 2017), despite its conflicting results in terms of clinical, social and financial outcomes and its negative impacts on the patients (Kisely et al., 2017). The coercive dimension inherent to the ITO poses many challenges for the nursing practice, as nurses must promote recovery and self-determination while having to impose an unwanted treatment (Corring et al., 2018). Since the nurse-patient therapeutic relationship is the cornerstone of mental health nursing, allowing many benefits for the patient’s health and well-being, it is essential to better understand the influence the ITO has on this relationship. Few studies have been carried on the therapeutic relationship in the context of ITOs, which does not allow for a comprehensive understanding of the subject. Guided by the Recovery Alliance Theory (Shanley et Jubb-Shanley, 2007), this study aimed to describe the therapeutic relationship in the context of ITOs as reported by nurses and individuals living with a mental illness. Secondary data analysis of qualitative data was performed from individual interviews with nurses (n=9) and patients who are or have already been on an ITO (n=6). Data were collected from three mental health and forensic psychiatric institutes and were analyzed using a process of content analysis (Miles et al., 2020). The therapeutic relationship was described as fundamentally imbedded in a power imbalance amplified by the ITO. Results highlight the complex links between the therapeutic relationship and the ITO and the divergent perspectives of nurses and patients on the possibility to develop this relationship. Patients rejected the possibility of developing a trusting relationship in this context, describing interactions with nurses as superficial, utilitarian, and unidirectional. The nurses’ perspective showed that nurses do believe in the possibility to build a therapeutic relationship despite the challenges caused by the ITO. Indeed, the ITO generates conflict between the different roles of the nurses, one being guided by their legal responsibility and the other by their professional practice. In light of these results, nurses should be made aware of the perception of patients on ITOs, while benefiting from support to assist them in the management of this measure which brings many challenges to their practice and to the development of the therapeutic relationship. Further studies should explore possible solutions to allow the nurse and the patient to develop a therapeutic relationship outside the constraints of the ITO.

Keyphrases: Psychiatrie, Therapeutic relationship, Nurse-patient relationship, Involuntary treatment order, Mental health, Psychiatry, Forensic psychiatry, Nursing