Un état de stress post-traumatique chronicisé est difficile à détecter compte tenu de la multiplicité de ses manifestations cliniques. Nous sommes confrontés à un problème diagnostique, dans la mesure où les expressions de l’ESPT chronique ne rencontrent plus les critères cités dans le DSM IV. Le dilemme qui se pose dans ce cas est : comment rendre compte de la tonalité « traumatique » sans faire de l’ESPT une catégorie « fourre-tout » ? Nous avons résolu cette question en adoptant la vision de M. Struber qui propose d’envisager la notion de stress post-traumatique comme une grille de lecture clinique. Cette lecture particulière présente l’avantage de reconnaître que le patient a des raisons « défendables » pour ne pas être arrivé à faire face à un événement dont on reconnaît qu’il a eu pour lui un réel impact « traumatique ». Nous avons expérimenté cette grille de lecture dans notre activité d’urgence psychiatrique et découvert qu’elle pouvait constituer un puissant levier thérapeutique dans la mesure où elle permet de rendre une compétence au patient, de s’éloigner des seuls enjeux de contrôle et donc d’éviter les « bras de fer ». C’est un recadrage qui ouvre la voie d’une coopération thérapeutique active, garante des futurs progrès du patient.

Chronic Post-traumatic stress disorder (PTSD) is a very complex syndrome which is hard to detect because of the multiplicity of its expressions. Further more, these clinical expressions are far from the « pure » syndrome described in the DSM IV. So, the clinician faces a dilemna : how can he account for the traumatic clues without using the PTSD as a ragbag of a diagnosis ? We found the way to discard this dilemna when we decided to use what M. Struber said about her experience with cancer and PTSD. She suggests not to emphasize psychopathology and to use a post-traumatic stress framework. This way to reframe some psychiatric urgencies is very useful because it gives back ability to the patient. When using a post-traumatic stress framework we tell the patient and his family that we acknowledge he has defensible reasons for not managing with an event which, we acknowledge too, was traumatic for him. In that way we begin to explore what each person is experiencing, because the traumatic experiencing is generally shared by the patient and his family. The members of the family are often angry and fed up of the patient behaviour and think themselves as victims of him. On the other part, the patient feels himself as a misunderstood person, victim of the others. The primary trauma is forgotten for a long time or nobody make any link between it and what is happening in the present. The manifestations of the PTSD initiate subsequent aftermaths and suffering for everybody. When working with psychiatric emergencies, we have to manage with acute situations in which each people is both victim and aggressor and in which clinicians run the risk of being given the role of either victim or aggressor. The trial of strength played between the patient and his family is going to be played with the clinician. These situations are described by S. Lamarre when she speaks of « victimisation » and are overloaded with control stake. Each one tries to make the other guilty and disgraced, and the clinician is at risk to feel and/or make feel in the same way the patient and his family. These situations are blocked and the temptation is to resort to a kind of coup when the clinician decides it’s enough ! and forces his opinion and decision. What is not a very good way to create the essential therapeutic co-operation ! In this article we show how using a post-traumatic stress framework is very useful to reframe the situation of « victimisation », give the opportunity to discard its trap, open a new sight which allows to find new solutions and promote a therapeutic co-operation. It’s important to stress the fact that it’s not efficient to use a post-traumatic stress framework as a formula. The clinician who uses it has to feel it, otherwise he will be unable to co-create this new reality with the system he entered, when receiving the emergency.