The major themes that emerged from the analysis were grouped into the following conceptual framework: 1) MHPs highlight important organizational and institutional challenges that they feel are beyond their scope; 2) MHPs mention in parallel their own perceptions and representations of TPE in the context of mental health care, 3) MHPs’ representations could hide a lack of knowledge or awareness that would prevent them from appropriating TPE programmes. For each major theme, the sub-themes identified are presented.
1-. MHPs highlight important organizational and institutional challenges that they feel are beyond their scope.
1.1-. The TPE would be too time consuming
The professionals described a lack of institutional will to provide TPE in their facility due to the lack of time dedicated to this additional activity.
"I think that in fact the difficulty of TPE comes from the fact that it has not been sup-ported by anyone specific...". .../.... (Doctors) "they don't have much time. They are re-ally busy with all the protocols. They have more and more things to do..." .../... "They don't have much time. .../... " And then there's so much work too, so much nursing and care assistant work, that it's not easy to detach yourself. We could do it but at the expense of something else". "In the evening, they have finished their day, they want to go home, I understand them, I really don't blame them, but they want to go home. They have their children too, they have their mother to visit, they have their life. And to commit oneself like that to something very regular is clearly a constraint".
In France, psychiatry suffers from a significant shortage of caregivers, which has a major impact on the implementation of new activities.
1.2-. High turnover of professional staff within the units
The respondents also presented the issue of high staff turnover because of the difficulty of the work as a factor that was detrimental to the sustainability of the programmes, whether this was due to personal or institutional causes.
"I was running a workshop with a health executive who left the hospital. And so I found myself... a bit on my own with this..." .../...
"Another obstacle that everyone in the hospital knows, and this was the case for the unit I was talking about, is that in fact all the care workers change departments every 5 years..." .../... "This is really a big obstacle. Because if there isn't a team of carers who can come and re-mobilise, re-explain the origin and re-initiate work on these programmes, on these tools, people find it difficult to re-appropriate them and they have to run a programme that was created by others...”
1.3-. Institutional communication needs to be improved
The lack of centralisation and institutional organisation also seemed to be lacking within the institutions and accentuated the feeling of having to manage alone and of lacking visibility in the running of the programmes.
"There must have been four or five professionals who really wanted to get involved. We were lucky enough to have the support of the managers, who made it possible for us to make up for the time taken up personally to structure our workshops.”
"When we asked for a bit of material, we had it all, right away. No, we were lucky in that respect, yes.
On the other hand,
"At the beginning, it was really word of mouth, there would have been no communication if the doctor who was at the initiative of this project had not done a bit of pushing, creating meetings, inviting people, inviting the different partners, we made flyers, brochures, we tried to talk to a lot of people. And it's true that little by little our colleagues began to understand the interest in better perceiving the indications and why we could propose that, why we could also think like that.”
2-. MHPs mention in parallel their own perceptions and representations of TPE in the context of mental health care
2.1-. TPE and the emergence of a conflict of values
In its approach to care and the new type of relationship with the patient, TPE is contrary to the culture of psychiatric care that carers are used to. The culture around medical care seems to be still strongly anchored in a paternalistic model where the doctor is the decision-maker on what the quality and philosophy of life of the patient should be. “I think that doctors, or even nurses, like to control, to know everything, and not to leave too much autonomy…”
Generally speaking, the idea emerged that the initial training of MHPs leaves too little room for the personalisation of work, group work and the development of social skills, which hinders the development of cooperation.
We are all used to receiving educational content in a rather formatted, vertical way…”, “Really one-sided, yes. And so that's totally the opposite of what TPE can be, to-tally…
And, in psychiatry, perhaps we are a little behind in this respect, a little behind, be-cause... well yes, clearly diabetes and pneumology have made a lot of progress in all this. And I think that for years, psychiatry has been watching all this progress, that's it!...
The participants recognize that the organisation of practices is rigid and difficult to change because it calls into question the meaning of “care” in psychiatry.
When I told colleagues from other departments that were doing therapeutic education in psychiatry, they looked at me wide-eyed when in fact ... it’s still shocking, that's all!
Even though the general management of the participants in the study had approved the training for TPE, contradictory orders in the field made it difficult to implement these practices and created a conflict of values and a loss of meaning for them.
Behind all this, it is the importance of the meaning we give to all this!
2–2. TPE seen as a fad
Some carers, in the context of the current strain on psychiatry units, considered that it was necessary to distance themselves from TPE by considering it to be an ephemeral "trend" within the context of the current issues in psychiatry.
"There is a new thing, it's a trend, it will go as it came, that's it..."
3. MHPs’ representations could hide a lack of knowledge or awareness that would prevent them from appropriating TPE programmes.
3 − 1. TPE is not well known
Some MHPs justified the opposition to TPE in psychiatry by a lack of knowledge of TPE among psychiatric carers. Others acknowledged that they did not have sufficient knowledge of TPE and had difficulty distinguishing it from psychoeducation, which is more widely practiced.
There was nothing to stop me from advocating TPE: I just didn't know about it!” …/….” For me, it wasn’t part of the care
Psychoeducation programmes have been developed for people living with psychiatric disorders. They are defined as systematic didactic and psychotherapeutic interventions that aim to inform patients and their relatives about the psychiatric disorder and promote coping skills. Beyond the transmission of information, psychoeducation is a pedagogical method with the aims of identity clarification and empowerment . The aim of TPE is to help patients acquire or maintain the skills they need to manage their lives with a chronic illness to the best of their ability, with the aim of acquiring and maintaining self-care skills and mobilising or acquiring coping skills based on the patient's previous experience. The distinction between psychoeducation and TPE remains blurred.
I talk about TPE, and in fact it's systematic: every time, when people manage to understand a little bit what TPE is, they say "But in fact, we do it every day! Well, yes! Except that the representation that people have of TPE is not the right one! It's not just about giving information to patients, to make them overly responsible and then let them manage! ...” …/…“The training in TPE proved to me that people were like me, ignorant! ... Because in fact, we do a workshop ... without a goal, without an objective, without a care project with psychoeducation! Whereas in TPE, there is a care project. We know what it should lead to and we know where the patient is at...
Our study revealed a paradoxical situation in that although MHPs have been trained to provide TPE, they have difficulty distinguishing it from psychoeducation. It is possible that the quality of the training received needs to be reviewed.
3 − 2.The highly formatted framework of TPE is not adapted to the problems of psychiatry
In France, TPE is considered as part of the patient care pathway. It aims to make patients more autonomous by facilitating their adherence to prescribed treatments and improving their quality of life. These programmes must be authorised by the Regional Health Agency (ARS). The conditions of authorisation provide a strict framework for the composition of the educational teams, the skills required to provide TPE and the teams that take the courses.
We had our ARS file turned down many times; it was never right. The doctor persevered, we never got a positive response, we ended up giving up, and so each year we tried to modify the programme, to adapt it according to ...” …/… “So, yes, honestly, it was all Greek to me. For me, it was really constraints that served no purpose; I didn't see the point of submitting a file to the ARS.”…/… “Because it was totally beyond me, I didn't really care”…/… “there are so many criteria... “ …/… Doctor XXX, I think she must have made 4 or 5 reminders, files, and at the last one we said, is it really useful to continue, and we said no. So, we are not called a ‘Therapeutic Education Group’, we are called a ‘Psychoeducation Group’, we are not recognised, we are not registered in the official booklet of existing groups that we will see on the ARS.
The conditions required for authorisation are poorly adapted to the functioning of psychiatric professionals, and have discouraged a number of initiatives. Although mental disorders are chronic illnesses, the TPE framework seems more suited to the management of a physical disorder because it was originally designed on a regulatory basis within that framework. Adaptations seem necessary.
3-3-. Mistaken representations of TPE
Some caregivers reported that there was a form of refusal of the principle of TPE for some MHPs. This negative outlook was sometimes linked to a generational effect, ex-plaining divergent representations of TPE.
"I think that doctors, even perhaps doctors or even nurses, like to control, to know everything, and not to allow too much autonomy, but, well...”
"There was one major obstacle: a general practitioner who was totally opposed to all this.../.... Radically. So it was impossible, even for things that are very common, namely insulin injections, self-injections of insulin, it was impossible! You couldn't... and that's how it was!”
"Afterwards, it is perhaps also a question of generation but also undoubtedly of personality...”
3–4. -Lack of TPE training in initial/continuing education
Insufficient training in TPE, whether in initial and/or continuing education, has been identified as a major barrier to the dissemination of TPE knowledge and culture among psychiatric workers. "So no, it was not at all a transversal thing in my training...".../... "Yes it was something optional, but it was optional, or rather over-optional".../... "It changed for the nurses, it was a portfolio to fill in with boxes, crosses and things, there were no more notes, so I was in my second year, so we saw, vaguely, therapeutic education in class, it must have been on the syllabus but really minor, eh : 2 hours...