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33научные обзоры и сообщения reviews and lectures
DOI: 10.12731/wsd-2016-11-42-56 UDC 616.89-02-084
MODERN REHABILITATION TENDENCIES IN PSYCHIATRY (LITERATURE REVIEW)
Samoylova D.D., Barylnik J.B.
In article the main directions of rehabilitation in psychiatry are considered. The process of rehabilitation is consecrated in the context of prophylaxis of psychic patients' disability as the main method. The value ofpsychoeducation programs as modern direction of rehabilitation actions in psychiatry is emphasized. The questions of psychosocial rehabilitation as one of the most important direction of psychic patients ' social functioning improvement are raised. The processes of psychosocial therapy and psychosocial rehabilitation in the context of occupational therapy as necessary and complementary therapeutic strategy are covered in modern psychiatric service in Russia.
Keywords: rehabilitation; psychic patients; social functioning; occupational therapy; psychoeducation.
СОВРЕМЕННЫЕ КОНЦЕПЦИИ РЕАБИЛИТАЦИИ В ПСИХИАТРИИ (ЛИТЕРАТУРНЫЙ ОБЗОР)
Самойлова Д.Д., Барыльник Ю.Б.
В статье рассмотрены основные направления в реабилитации в психиатрии. Процесс реабилитации освящен в контексте метода профилактики инвалидизации психически больных. Подчеркнуто значение психообра-
зовательных программ как современного направления реабилитационных мероприятий в психиатрии. Затронуты вопросы психосоциальной реабилитации как одного из важнейших направлений улучшения социального функционирования психически больных. Освещены процессы психосоциальной терапии и психосоциальной реабилитации в контексте оккупаци-ональной терапии как необходимые и взаимодополняющие терапевтические стратегии в современной психиатрической службе в России.
Ключевые слова: реабилитация; психически больные; социальное функционирование; оккупациональная терапия; психообразование.
Nowadays there is the variety of actual tendencies along with the traditional approach to rehabilitation in psychiatry. Psychosocial rehabilitation and occupational therapy are the most often met methods according to different publications. The great amount of concepts is considered in different literary sources. In particular they are described in «The world report on disability» of the World Health Organization (WHO) Committee (2011), the report of the WHO «About the health care condition in Europe» (2012) and the European declaration of mental health care (2005). However, the systematic overview and the analysis of these concepts is still absent.
The goal of this article is to consider and analyze the literary sources covering the actual tendencies of rehabilitation in psychiatry.
Rehabilitation always had the major place in mental health services system. The classical concept of psychic patients' rehabilitation is based on the complex approach where the patients are considered as the difficult system having different levels of functioning. In the center of the medical rehabilitation attention there are such consequences of diseases which are appeared in functional disabilities and social disintegration [12, p. 332].
The modern rehabilitation concept is very wide and assumes the combination of medical, public and governmental activities which purpose is the possible compensation (or recovery) of the disordered or lost functions and social readaptation (or adaptation) of patients and disabled people [3, pp. 61-64]. Medical rehabilitation is determined by the WHO Committee as «the com-
bined and coordinated use of medical and social measures, learning and professional training or retraining aiming to provide the highest level of functional activity to the patients» [2, p. 15].
Rehabilitation assumes the reduction of the disabling factors and prevention of patients' disability and contains a complex of measures allowing to reduce the dysfunction frequency. It promotes the restriction of degree or redevelopment of disability and prevents transition of disability to physical and other defects. The final goal of rehabilitation is returning to an active labor activity according to patient's functionality. The optimal solution of this problem is considered as the full revival of former professional activity of the rehabilitated person. In case of such task failure in the conditions of pathological regeneration of the carried-out rehabilitation can be considered as effective in case of self-service and self-sufficiency capabilities recovery with the subsequent material independence of the patients [3, pp. 61-64].
According to the European declaration of mental health care, psychic patients' rehabilitation is the tool for people with limited opportunities of integration in society. It is the mechanism of equal opportunities creation for such patients. The purpose of medico-social rehabilitation is considered as complete or partial recovery or saving of the patient's personal and social statuses. It includes medical rehabilitation referred to achievement of the highest clinical compensation, stopping of illness implications and prophylaxis or decreasing of it's undesirable consequences. Professional and social rehabilitation are also the part of medico-social concept.
According to the WHO report «About the health care condition in Europe» (2012), the guide approach to assessment of the illnesses burden means that only through the careful analysis of all known sources of information which are available in the country or the region and correction of systematic error of measurements can receive the best estimates of morbidity, prevalence and a mortality rating. DALY indicator (disability-adjusted life-year, years of life adjusted for vital activity restrictions) is developed for assessment of illness burden. It is the summary of indicators combining the years of life lost as the result of premature death and the years of life which were partially lost because of incomplete health
living conditions. The way of DALY calculation which is the quantitative health index of the population and one of the primary points for formation of health care policy accurately shows that the mortality is not the only component of the illness burden. The appreciable part of this burden is the morbidity and restriction of life opportunities (disability). Calculation of the lost DALY allows to measure the decrease in comparison with potentially ideal, faultless health when people have no illnesses or disability and all of them reach the highest indicators of the expected life expectancy registered in the world [5, pp. 42-44].
Nowadays the integrative approaches which determine the modern standard of patients' care are the noticeable directions in psychiatric practice. Rehabilitation is reached by the combined application of a number of actions: medical, psychological, physical, pedagogical, social, legal and others which constitute the unified complex [7, pp. 485-489].
Rehabilitation is not only the prevention, treatment and employment, but the essentially new approach to the patient's resocialization, recovery of the personal and social statuses. The appeal to the personality was selected as the main core of rehabilitation programs. During the rehabilitation and treatment in psychiatry such trend as «socially-psychiatric» approach begins to take the important place. The multifactorial etiology of mental disorders, the knowledge of biopsychosocial etiopathogenetic determinants of the diseases more and more determine not only the conceptual theoretical approaches, but also become a basis of wide practice in psychiatry [13, pp. 795-810].
The main conducted public tendencies of assistance and rehabilitation in psychiatry are [9, pp. 15-23]:
1. Correlation researches of social support level and the condition of mental and physical health;
2. Correlation researches of social support and a capability to cope with problems, to get successfully out of stressful situations;
3. Researches directed to clarification of various key figure functions of social network (friends, relatives, spouses, etc.);
4. Researches directed to identification of the person's capability to create an effective social network;
5. Researches directed to detection of social networks and social support features in case of various mental disorders.
The attention to sociology of medicine becomes noticeable. The rehabilitation here means the expansion of the activity patient's spheres by complex means of medico-biological, social and psychological actions which final goal is complete or partial recovery of the patient's personal and social statuses [6, pp. 477-480].
There are four principles of psychic patients' rehabilitation in Russian psychiatry [11, pp. 97-101]:
1. The partnership between the doctor and the patient providing the addressing to the identity of the last;
2. The versatility of the efforts and actions directed to the different sheres of psychosocial functioning;
3. Unity of biological and psychosocial impacts directed to recovery (preserving) of the patient's personal and social statuses;
4. Gradualness, transitivity of the efforts and actions causing achievement of the final goal of rehabilitation, recovery, preserving of the patient's personal and social statuses.
There are three stages of psychic patients' rehabilitation:
1. The recovery therapy directed to the prevention of mental defect forming (disability), the phenomena of «hospitalism», liquidation or reduction of these phenomena;
2. The patient's life adaptation and a labor activity in extramural conditions;
3. The recovery of patient's individual and social values.
The individual rehabilitation programs include such main aspects as medico-biological, psychological and social. The following scheme of rehabilitation programs is preferable:
1. The creation of the patient's therapeutic hospital area;
2. The overcoming of an anosognosia and increase of patient's psychological literacy;
3. The individual and group psychotherapy directed to awareness of own personal features and psychological problems;
4. The individual and group work with patients directed to increasing of their social adaptation level, forming of responsibility for the social behavior, training skills of constructive communication, overcoming conflict situations.
One of the most actual tendencies of modern psychiatry is psychosocial treatment and psychosocial rehabilitation. Psychosocial treatment is the indispensable component of socially oriented mental health services or mental health service with a community support. As it was specified in the WHO report in 2011, psychosocial rehabilitation becomes not just the method, but the comprehensive process [3, pp. 61-64].
Psychosocial therapy and psychosocial rehabilitation become the real component of rendering psychiatric help in many psychiatric organizations. These forms of assistance gain development on certain sites, in separate organizational extra hospital links, departments of hospitals or in specially oriented sections of mental health services of number Russian regions. Moreover, their distribution finds out a noticeable tendency to expansion that it is substantially connected with approval of multiprofessional brigade approach to rendering psychiatric help with participation in it of not only psychiatrists, but also psychologists, psychotherapists, specialists in social work and social workers [14, p. 348].
Psychosocial rehabilitation is the recovery of disabled (forming - in case of initial insufficiency) cognitive, motivational, emotional personality resources (including skills, knowledge, abilities to interact, solve problems and so forth) in psychic patients with defects of social adaptation, providing their integration into society. The complex of psychosocial impacts is various forms and methods directed to potential patient's recovery that makes his efforts for society position achievement more complete or equal with others. The authors who are engaged in rehabilitation have already emphasized the important role of active patient's participation in rehabilitation process. However the methods of direct psychosocial impact were limited at that time as they had the mediated, indirect character. For example, the people involved in labor processes out of psychiatric hospitals at the same time improved their skills of social interaction or independent accommodation [14, p. 348].
There are three stages of psychosocial rehabilitation:
1. The stage of active psychosocial impacts (psychosocial therapy).
This stage of psychosocial treatment uses various forms of the psychosocial impacts directed to recovery of cognitive, motivational, emotional resources taking into account the features of social disadaptation caused by them. This last circumstance requires the corresponding adequate forms of psychosocial impacts as usual.
The beginning of psychosocial rehabilitation process does not necessarily match the patient's staying in hospital. It may begin at any period of psychic assistance rendering. The fact that the determination of etiology and extent of social disadaptation needs in this or that specific form of psychosocial impact is very important. It is usually a stage of the most active psychosocial impacts.
2. The stage of available for the patient skills practical development.
Generally it is the function of all «intermediate» (between mental health
facilities and society) organizational links which are bringing closer the patient (by step practical development of social roles and line items) to life in the population. At the same time it is the process of the recovered skills and abilities (received by applying of various forms of psychosocial impacts and models) «generalization» in relation to harder social relations and requirements, expecting the patient in case of his life return.
3. The stage of fixing and supporting of incomplete or complete social recovery [8, p. 30].
Psychosocial rehabilitation is the forming or recovery of the insufficient or lost because of the disease cognitive, motivational, emotional personality resources, skills, knowledge, abilities to interact, solve problems, to use different strategies providing psychic patients integration into society. At the same time the purpose of the psychosocial rehabilitation approach is ensuring balance between mental life of the subject in a situation of the disease and the social relations influencing his activity and social adaptation [3, pp. 61-64].
Nowadays the most common forms of psychosocial rehabilitation are psy-choeducation of patients and their relatives, individual case management, in-
tensive (persistent) treatment in community, family therapy, a training of social skills, the protected employment, «housing with support» [3, pp. 61-64].
The psychoeducational program is considered to be better hold at different stages of the disease. The better results are achieved in case of early inclusion of psychoeducational programs in the complex of medical and rehabilitation actions. Psychoeducation promotes stimulation of the patient's active position in overcoming his disease and it's consequences, the increasing of social competence, responsibility and development of adequate protective strategy from the disease [8, p. 30].
There are two main objectives of psychoeducational programs:
1. «The education» when the patient obtains the information about mental disease to have the correct understanding of it conducted to timely recognition and control of it's separate manifestations.
2. «Psychosocial support ensuring» when the group is a fixed source of the patient's support and at the same time therapeutic environment for patients' protection, emotionally safe conditions to develop adequate behavioral skills, communication, a coping with difficult situations. Besides, the needs for communication are satisfied by participation in support group.
Psychoeducation has the significant influence on the efficiency of patients' functioning in the environment and less in the sphere of their interpersonal functioning [8, p. 30].
One of the most common forms of psychosocial rehabilitation is individual compliance therapy of patients with schizophrenia. Compliance therapy is a therapy specifically designed to improve concordance with treatment for those with major mental illnesses, but its effectiveness in patients with schizophrenia is controversial. It is a cognitive behavior intervention with techniques adapted from motivational interviewing and psycho-education therapies. Kemp et al. described «compliance therapy» causes to better drug compliance, attitudes to treatment, and insight at final of intervention; however, some studies did not confirm it [19, p. 258].
The anglicisms «compliance» and similar terms need to be clarified because of the lack of terminology common understanding. The term «compli-
ance» means a measure that characterizes the correct implementation of the physician recommendations: drug treatment, non-pharmacological treatments, lifestyle changes, etc. The term «adherence» is also used. Foreign authors (especially in the UK) increasingly use the concept of «consent to treatment» (concordance with medication). These terms («compliance», «adherence», «consent to treatment») are inadequate. The term «compliance» is endowed with a bright shade of paternalism, as it believes that the correct compliance with medical advice to patients without regard to his own relationship to treatment. The principle of partnership, on the basis of which it is recommended to build a relationship of doctor and patient at the moment, determines the preference of using the term «consent to treatment». This concept takes into account the patient's point of view in relation to the therapy. Some authors use the concept, the interpretation of which is even more wide «therapeutic part-nership» and «therapeutic alliance». These terms describe not only the correct observance of the following to doctor appointments and their agreement to adhere to medical recommendations, but also the quality of the relationship with the patients health care system (e.g., the desire to go to a medical institution, the degree of confidence in the doctor, and so on). Despite the difference in semantics, in the conditions of everyday clinical practice these concepts are generally interchangeable and are used mainly to characterize the correct patient compliance to drug therapy [4, pp. 4-12].
The commitment is the key therapeutic administration of medical care point. However, in routine clinical practice this phenomenon is given far less attention than it is required [18].
A rough estimate of up to 50% of patients suffering from chronic diseases, do not take the treatment properly after 6 months [20, p. 311]. According to the literature, the incidence of non-compliance by patients' regimen of antipsychotic drugs varies between 11-80%. A very important factor is the fact that patients have trust relationships, as well as understanding and proper contact with the doctor who is interested in participation in the process of therapy to minimize the violation of prescribed medical advice. These circumstances make it necessary to create a so-called therapeutic alliance, the maintenance of which is an import-
ant indicator of medical professionalism and guarantee the successful therapy [1]. A number of factors influence adherence to treatment, so to be successful it is important to use an individual approach. It should also take into account the peculiarities of the health care system and assist. This includes such aspects as the time allowed for the study of the potential factors affecting the commitment of carrying out activities aimed to psychoeducation (of patients and their family members, if necessary), creating an atmosphere of shared decision-making and strengthen the therapeutic alliance. It is also important to take into account the frequency and continuity of care and clinician's ability to monitor compliance with the use of various methods that have been discussed previously [15, p. 44]. Availability curators, consultants on healthy lifestyles and/or peer educators can play the role in improving of treatment adherence. Personal characteristics of family members/caregivers are another factor having the potential impact on adherence. It is also important the degree of their involvement in patient cane in the fight against disease and the level of psychoeducation received by them. Clinicians should try to understand and take into account their knowledge, beliefs and attitudes, the nature of the relationship with the patient and their possible role in the monitoring and improvement of compliance [16].
Traditionally, psychoeducation is a key strategy to improve adherence, but it is encouraged to use new and psychosocial approaches. Undoubtedly, the optimization of drug therapy is the key step on the path to improvement compliance. New developments may also contribute to this. Psychosocial, pharmacological and technological approaches should complement each other to maximize the potential return [17, pp. 216-226].
In the conclusion we note that there is the noticeable trend of occupational therapy in Russian mental health service [2, p. 15] for recent years. According to M.F. McColl (1993) the daily activities in which the person is involved, including self-care, leisure and professional activity are called occupational. The balance between them has the essential value for life, health and well-being of each person. Main objectives of occupational therapy are: elimination of restrictions or activities insufficiency; ensuring successful and independent accomplishment of occupational actions and social roles by individuals; expan-
sion of independence and autonomy of the person in everyday life through his involvement in the occupations. Forming of skills and creation of conditions of the maximum independent self-service, productivity and available leisure for people with physical or mental disorders is one of the most important aspects of the occupational therapy professional activity. Occupational therapy is connected with the development of new social skills, examples of behavior and lifestyles. It provides active social participation of physically disabled people, their effective secondary socialization and worthy quality of life [10, pp. 6-9].
The overview of modern concepts of rehabilitation in the analyzed literary sources showed their variety and essential complication of modern system representations. The variety of tendencies and ambiguity of approaches to rehabilitation in psychiatry testifies the need of psychoeducational programs development [6, pp. 477-480].
References
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20. Tarn D.M., Paterniti D.A., Kravitz R.L. et al. How much time does it take to prescribe a new medication? Patient Educ Couns 2008;72:311-9.
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20. Tarn D.M., Paterniti D.A., Kravitz R.L. et al. How much time does it take to prescribe a new medication? // Patient Educ Couns 2008;72:311-9.
DATA ABOUT THE AUTHORS Samoylova Daria Dmitrievna, PhD, Assistant of Professor of Psychiatry, Narcology, Psychotherapy and Medical Psychology Department
Saratov State Medical University n.a. V.I. Razumovsky
112, Bolshaya Kazach'ya Str., Saratov, 410012, Russian Federation
SPIN-code: 6597-6390
Barylnik Julia Borisovna, MD, Head of Psychiatry, Narcology, Psychotherapy and Medical Psychology Department
Saratov State Medical University n.a. V.I. Razumovsky 112, Bolshaya Kazach'ya Str., Saratov, 410012, Russian Federation [email protected] SPIN-code: 9289-5648
ДАННЫЕ ОБ АВТОРАХ Самойлова Дарья Дмитриевна, кандидат медицинских наук
Саратовский государственный медицинский университет
ул. Большая Казачья, 112, г. Саратов, Саратовская обл., 410012,
Российская Федерация
Барыльник Юлия Борисовна, доктор медицинских наук, врач-психиатр
Саратовский государственный медицинский университет
ул. Большая Казачья, 112, г. Саратов, Саратовская обл., 410012,
Российская Федерация
