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Section 6. Medical science
Section 6. Medical science
Poplavskaya Olga, Volgograd State Medical University, Teaching Assistant of the department for Psychiatry, Narcology and Psychotherapy with the Course of Doctors Improvement Faculty,
Candidate of Medical Science, E-mail: poplavok9@rambler.ru Ioannidi Daria, Volgograd State Medical University, Resident of the department for Psychiatry, Narcology and Psychotherapy with the Course of Doctors Improvement Faculty
E-mail: Darien2@rambler.ru
Problems of social services persons with mental disorders in Russia
Abstract: The article is devoted to the problem of applicable federal legislation, concerning the interaction between outpatient psychiatric services and social services, providing social care for mentally disabled people. Keywords: mental disability, social care, outpatient psychiatric care.
The statistics show every year in Russia, the number of people with disabilities due to mental disorders is increasing, 60% of those with disabilities of working age, more than 80% live in families, improving their social functioning and quality of life is one of the most important areas of state policy [1, 5; 2, 50]. Understanding of preference and more effective of outpatient mental health services is increasing and support in the community of people with disabilities as well, compared with long-term stay in closed institutions, leading to the loss of social skills, excessive restrictions and reducing in opportunities of rehabilitation, that is often associated with violation of human rights [8, 3; 10, 253].
The social character of psychiatry necessitates discussions on measures to improve the quality of mental health and social care for patients with mental disorders, involving a broad range of specialists [3, 4; 7, 10; 9, 105; 11, 146].
Work of outpatient mental health services in the maximum extent is linked with social services, however, there remains insufficiently developed mechanisms of their interaction. Patients in neuropsychiatric dispensaries who are disabled due to a mental disorder are usually faced with a significant number of unresolved problems in the social area (housekeeping, rational distribution of often poor funds, the organization of employment and leisure activities). For these patients the problem of loneliness, lack of development of social networks is very acute, the existing problems in the
social area come to the fore (lack of documentation, unregistered facilities, utility debts), high demand for legal advice. Range of tasks supporting social work ranges from restoring basic skills for independent existence (hygiene practices, and self-service, housekeeping, use of transport, budget allocation, structuring of activities during the day) to overcoming the shortage of social skills, that are important for social functioning [8, 4; 11, 148; 13, 40].
Numerous scientific studies have shown that patients receiving high-quality social services become more compliance and as a result, reduced severity of psychiatric symptoms and the need for hospitalization, which allow resocialise patients, alleviate exacerbations of the disease, include patients in community life. At the same time, there is less pressure on the family for the care of a sick relative [8, 3; 11, 147].
When it is necessary to solve different social problems, patients and their families appeal to psychiatrist for medical aid, who is forced to deal with all the problems of their patients, either directly providing health services and social support, assistance in family, housing, legal and other issues that go far beyond the competence of the doctor. Undoubtedly, the quality of mental health care is higher if it is complex, with a team of experts — psychiatrists, psychologists, social workers, social educators. Multiprofessional approach — one of the generally recognized principles of mental health care at present [1, 9; 7, 8; 10, 12].
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Problems of social services persons with mental disorders in Russia
Using the qualitative method of sociology of medicine case-study classified the situation occurring in the provision of mental health care. We analyzed 73 cases. For the application of the method case-study is the selection of an exemplary embodiment in each individual case is the main aim.
Psychosocial interventions should be carried out in close collaboration with outpatient psychiatric services. However, the current legislation does not provide an effective mechanism for the interaction of neuropsychiatric dispensaries and services ofsocial services in the provision of social services to people with mental disorders. Thus, according to Article 18 of the Federal Law of August 2, 1995 N122-FL “The social services for the elderly and people with disabilities” (the Federal Law № 122-FL), procedure and conditions of socio-medical care at home are determined by the executive authorities ofthe Russian Federation [5, 3198]. In pursuance of this provision, first joint order ofthe Office of Social Security ofthe Volgograd Region Administration and the Committee on Public Health Administration ofthe Volgograd region was issued from September 21, 2007 NN942464 “The collaboration of outpatient health care facilities and public institutions of social of social services is to improve the health and social care for elderly people and people with disabilities at home” [4]. But this order did not establish the mechanism of interaction between health care and social services on this subject, limited to only certain general provisions relating to the promotion of one other service. There is no such mechanism in the new order of Ministry of Health ofthe Volgograd Region November 19, 2013 № 3132 and the Ministry of Social Protection of the Volgograd Region November 21, 2013 № 1167 «On approval of the interagency cooperation on issues related to the provision of senior citizens and the disabled state social service agencies for social services Volgograd region» [6].
The mechanism of interaction between the two services (outpatient mental health and social) is not established as well as in the state standard ofsocial services of the Volgograd area “Socio-medical rehabilitation of the elderly and people with disabilities in non-stationary conditions,” approved by the Order of the Ministry of Social Protection of the Volgograd Region 4 June 2012 N343 [12]. In addition, the current legislation leaves unanswered some issues related to the provision of citizens with mental illness, social services at home. For example, Article 18 of the Federal Law № 122-FL provides the possibility of social and medical care at home, which may be exercised in respect of the elderly and people with disabilities who need home-care
services, including with mental disorders (in remission) (with the exception of the diseases mentioned in the fourth part of Article 15 of the Federal Law № 122-FL). At the same time 4 part 15 of the Act, it is found that senior citizens and the disabled, who can have a severe mental disorder requiring treatment in specialized health care facilities, may be denied an access to social services at home [5, 3198]. Thus, the law establishes that the socio-medical home care services for senior citizens and people with disabilities, mental health problems, may be exercised only in finding them in remission. Moreover, the current legislation provides that senior citizens and people with disabilities may be denied in the socio-medical care at home, if they have a severe mental disorder requiring treatment in specialized health care, regardless of their remission. However, the law does not prohibit the provision of such citizens, and provides them the right to refuse in providing of services to the social-medical care, leaving the implementation of such rights at the discretion of social services. Use of these provisions in practice has a direct impact on the rights of citizens with mental disorders, as these norms establish the possibility of home care of individuals suffering from mental disorders. Moreover, if Article 15 of the Federal Law under consideration, determines that the denial of social services at home for senior citizens and people with disabilities, mental disorders, is confirm by the conclusion of a joint body of social protection and medical and health care advisory committee, so on the basis of document or manner determined by finding the citizen with a mental disorder, in remission, the current legislation does not set. At the same time, being a citizen in remission or subacute state of mental disorder may be relevant to the giving or denial of social services at home to citizens suffering from mental disorders.
The complexity of the application of the above rules of law may be illustrated by the following example. The patient G. from 1985 is observed in the psychoneurological dispensary about chronic mental illness. During the disease was permanently treated once in 1989 in inpatient hospital, since 2002 does not accept drugs, has a disability in mental illness. In connection with the medical condition, the patient a few years ago had surgery — amputation of his right leg at the level of the lower third of the thigh. Regional guardianship agencies asked the court about the recognition G. incapacitated due to mental illness. However, the judge did not find the arguments about the impossibility of the patient to understand the significance and control her actions convincing, G. was
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Section 6. Medical science
declared incapacitated. Thus, patient G. was in a situation, where she needed social support. It should be noted, that the patient’s mental illness is clinically expressed only in human thinking. She, in a special way, ornately was building inferences, in fellowship was intrusive and suspicious of people. At the same time she did not have aggressive tendencies, active delusional production. Nevertheless, G. caused ambiguous relation by social workers, as always a few calls to the establishment of the Department of Social Protection in detail figured out the identity of the employee who came to her, with himself thoroughly assistant, citing the current legislation, discussed the normal number of cooked meals, of cleaning the apartment, grocery shopping. Therefore, in every possible case, social workers tried to find a reason not to give her in-home services. Every month in neuropsychiatric institution of the place of residence G. sent letters to attract the district attention of psychiatrist for the issuance of a negative conclusion of the medical commission of the need of socio-medical care and home care. However, according to Article 15 of Federal Law № 122-FL, contraindications of the psychiatric disease were out.
This case is one of the examples, where the presence of a mental disorder can not be an automatic contraindication to social services at home. Although, the patient is disabled by mental illness, her mental disorder is can not be considered as severe and require treatment in a specialized institution. At the same time, it is clear, that the difficulties encountered by the expert of social services, not having sufficient knowledge and skills to communicate with patients with mental health. Through ignorance of the laws of development and manifestations of mental disorders, many social workers are afraid of patient, expecting of him any inadequate response, including illegal actions. Social worker, received theoretical and practical skills of working with persons with mental disorders, whom explained features of the medical, ethical and legal aspects of care for the mentally ill patient, would experience less difficulty in dealing with this patient. A trained specialist can perform additional special psychosocial activities (skills training for independent living, psychoeducational program with elements of cognitive training, training of social and communication skills), which can significantly enhance the ability to assist the mentally ill with disabilities.
There are cases, where social services at home receives a citizen, living with a mentally ill relative. At the same time social services refer to a mental hospital for a
“resolution" for further service of the citizen, considering that sick relative can be dangerous for the social worker. Such situations are not regulated by current legislation. It turns out, that it is impossible to determine the reasons for limiting the right to receive social services at home citizen, based on the mental state of living with his family members.
Thus, the problems associated with the issues of interaction of outpatient mental health services and social services may include: lack of a clear legal mechanism for the interaction of medical and social services, lack of training, education and prejudice against a social service professionals to work with persons with mental disease. This points to the need to improve existing legislation, such as the inclusion in the Federal Law № 122 [5, 3198] special rules, which clearly define the conditions and regulatory features of social assistance at home to citizens suffering from mental disorders. In addition, at the level of the Volgograd region it is necessary to adopt a legal act, regulating the procedure and conditions for socio-medical care at home. Such order should contain a clear mechanism for interaction hospital staff and social services with specific measures of interaction, the timing of certain actions within the framework of this cooperation and containing features providing social-medical home care of persons suffering from mental illnesses or people living with the persons with mental disorders.
It is necessary to create a separate specialized service, or a new division of the existing social services, consisting of medical workers (psychiatrists), adequately trained professionals in social work and social workers, functioning on a territorial basis. Therefore, it is necessary to establish a system of targeted training and retraining of staff of social workers for mental health. Also existing legal regulation of social care to patients with mental disorders should be supplemented with rules, regulating the activities of organizations, that are based on private ownership.
Commitment to the partner multiprofessional approach in providing mental health and social care for people with mental illness, with the creation of a broad coalition, including patients, their families, doctors and social workers, the understanding of high priority of the patients needs and their environment, the development of clear methods of interaction between different participants in the process, the ability to take timely necessary changes, will be key to improving the quality of life of one of the most unprotected categories of people — the mentally ill people with disabilities.
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Problems of social services persons with mental disorders in Russia
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