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17PSYCHOEDUCATIONAL MODULE AS A COMPONENT OF COMPLEX SYSTEM OF MEDICAL-
PSYCHOLOGICAL SUPPORT FOR FAMILIES, WHERE A PATIENT WITH ENDOGENOUS
MENTAL DISORDER LIVES
Kaminska A.
MD, PhD, Associated professor, Department of Medical Psychology and Psychiatry with the Course of Postgraduate Education of National Pirogov Memorial University, Vinnytsya, Ukraine
Pshuk N.
MD, PhD, DSci, Professor, Head of Medical Psychology and Psychiatry Department with the Course of Postgraduate Education, National Pirogov Memorial Medical University, Vinnytsya
Stukan L.
MD, PhD, Associated professor, Department of Medical Psychology and Psychiatry with the Course of Postgraduate Education of National Pirogov Memorial University, Vinnytsya, Ukraine
Abstract
Family environment of patients with endogenous mental disorders should be considered as a powerful source of socio-therapeutic resource for restoring patients' personality potential and contributing to their social adaptation. In this article psychoeducation is presented as one of the key approaches in multidimensional system of psychosocial rehabilitation. The article focuses on psychoeducation as an integral part of complex system of medical-psychological support for families, where a patient with endogenous mental disorder lives.
Keywords: psychosocial rehabilitation, psychoeducation, family caregivers, endogenous mental disorders, medical-psychological support system, family burden.
Recently, psychosocial therapy and rehabilitation of patients with endogenous mental disorders (EMD) as a form of psychiatric care has been widely recognized and used in Ukraine and in the world. In context of the biopsychosocial model of development of EMD, family environment of patients should be considered as a powerful source of socio-therapeutic resource for restoring patient's personality potential, contributing to social adaptation and achieving equal status in society [5, p. 162. At the same time, data from current research indicate numerous negative effects of living and interacting with a mentally sick family member, in particular for family caregivers, who take responsibility for the psychosocial support of a patient, associated with significant psychosocial burden [11, p. 100]. Patients with affective disorders and schizophrenia and their family caregivers often face discrimination, misunderstanding and stigmatization. At the onset of the disease, psycho-pathological symptoms can be difficult to understand and accept by family members, triggering a wide range of psychological reactions, that are not always constructive and conducive to the psychosocial rehabilitation and readaptation of the patient. Symptoms of affective disorders and schizophrenia are challenging for the family, where a patient with EMD lives [9, p. 508]. Some symptoms, such as hallucinations and delusional ideas, are often confusing and frightening, whereas depressive mood, suicidal thoughts and attempts, apathy, cognitive deficits can dramatically alter patient's personality, affecting emotional, cognitive, and behavioral reactions, in turn, it affects the entire family system and ultimately the disease course [12, p. 7].
In this regard, development and implementation of psycho-educational work into the complex system of medical-psychological support for families, where patients with EMD live, is an urgent task of modern medical psychology.
For domestic psychiatric practice, psycho-educational work with family caregivers of patients with
EMD is a fairly new type of psychosocial intervention. Meanwhile, in foreign literature psychoeducation is presented as one of the key approaches to the training and psychosocial treatment of patients with mental disorders and support for their family caregivers, and is considered as a significant component of psychosocial interventions in the multidimensional system of psychosocial rehabilitation.
The aim of our study was to substantiate scientifically a complex system of medical-psychological support for families, where mentally sick patient lives, from the standpoint of a systematic approach, based on the study of clinical and psychological manifestations and risk factors for the development of family functioning disorders in families, where patients with EMD live.
In order to achieve the aim of the study, 243 family caregivers (FC) of patients with paranoid schizophrenia (main group 1 - 168 persons, G1) and affective disorders (main group 2 - 75 persons, G2) were examined in 2015-2019 on the basis of informed consent with the principles of medical bioethics and deontology, using specially designed questionnaire and psychological testing tools.
The criteria for inclusion of the respondents to the study were: informed consent for clinical-psychological examination and psychological testing, no prior requests for help from a psychiatrist, no history of traumatic brain injury. Control group (CG) included 55 mentally healthy persons (35 female and 20 male), in whose families were was no mentally sick patient, and who had never sought for the help of a psychiatrist.
The work was carried out in three stages: at first stage we examined the respondents of G1 and G2 in order to study in depth social-psychological, individual-psychological, interpersonal-
communicative and behavioral predictors of family disaptation. The second stage of work included substantiation, development and implementation of an
appropriate system of medical-psychological support for families, where patients with EMD live, based on data obtained during the previous stage of work. At third stage, the efficiency of implemented system was evaluated.
On the basis of the analysis of the data, obtained during the first stage, we developed a theoretical substantiation and proposed an algorithm for a complex system of medical and psychological support for FC of patients with EMD. Targets of psychocorrectional influence, aimed at the development of constructive behavior and improving quality of interpersonal communication of patients with EMD, were defined.
Integrative approaches were used including the following methods:
- cognitive-behavioral psychotherapy;
- mindfullness-oriented cognitive therapy;
- psychotraining;
- art therapy.
Choice of the method of psycho-corrective intervention and specific content of psycho-correction sessions were determined by the actual goals of psychocorrection.
The proposed system of measures was aimed at forming an adequate attitude of family caregivers towards the illness of a family member, improving communicative competence through formation of empathic skills, effective communication and adaptive coping behavior, creating favorable conditions for activating communication resources and enhancing adaptive personality potential.
The objectives of the system were:
1) providing FC of patients with realistic ideas about causes, mechanisms of development, peculiarities and consequences of the disease, understanding possibilities of its treatment, prognosis, as well as importance of socio-therapeutic environment for social adaptation of patients and prevention of stigmatization;
2) formation of the ability to predict consequences of their behavior, to understand manifestations of verbal and non-verbal communication, to be guided in the overall picture of interpersonal interaction;
3) mastering skills of constructive coping behavior under stress conditions;
5) creating conditions for expanding the range of emotional response and development of reflection in process of interpersonal interaction;
7) creating favourable conditions for forming adequate interpersonal interaction in family;
8) creation of preconditions for development of value-based attitudes aimed at preserving health and activating personal adaptive capacity in FC.
In terms of content, proposed system of medical-psychological support for FC of patients with EMD is a three-component structure (Fig. 1):
1. psychoeducational module aimed at psychoedu-cation of family caregivers of patients with EMD on the causes, mechanisms of formation, approaches to treatment and consequences of mental disease;
2. practically oriented module (psychotraining, group and individual psychocorrection work in cognitive-behavioral approach, mindfulness), aimed at enhancing awareness of feelings, deepening of self-understanding, activation of adaptive potential, involvement of personality resource components, working out intrapersonal and interpersonal conflicts related to the illness of a family member, expression of negative emotions;
3. developmental module, based on psychotrain-ing as a special form of work with an individual and a group, aimed at acquiring knowledge, skills, assimilation of effective ways of communication, activation of communicative resources through such methods as group discussion, modelling of family situations, art-therapeutic techniques.
I module - psychoeducational. Tasks: theoretical awareness-raising for family caregivers about mental disease problem, building motivation for further psychocorrective work.
II module - practice-oriented.
Tasks: enhancing resilience, development of psychological self-regulation skills, creating conditions for activating personality adaptation potential, activating personality communicative resources, communication competrence development.
Ill module - developmental.
Tasks: learning constructive coping-behavior skills.
Fig. 1 Algorithm ofpsycho-corrective measures for family caregivers ofpatients with EMD
Our system provides combination of group and individual forms of psycho-corrective work with the use of appropriate means, techniques and methods of psycho-corrective influence (Table 1).
Table 1
Targets and content of an integrative system of psycho-corrective measures for family caregivers of __patients with EMD__
Target Aim Means
- dramatic or negative attitude towards the patient 1. development of an adequate type of attitude towards the patient; 2. elimination of dramatic and negative tendencies towards the patient; 3. realistic, conscious and responsible attitude to the disease, its treatment and its possible consequences; 4. raising the level of social adaptability of the family as a whole. Psychoeducation, group psychocorrection, cognitive-behavioral psychotherapy
- pathological psycho-emotional state 1. reducing overall stress; 2. normalization of psycho-emotional state; 3. reducing the level of neuroticism; 4. actualization of personal resources of self-change; Art therapy, mindfulness-oriented cognitive therapy
- decrease in communication resource, negative communication attitude, insufficient development of social intelligence 1. development of empathic and affiliation resources; 2. reduction of sensitivity to neglection; 3. formation of communicative competence 4. raising the level of social adaptability and restoring satisfaction with social achievements Group psychocorrection, communication competence training, mindfulness
- maladaptive behavioral patterns 1. mastering coping skills; 2. enhancing stress resistance and psychological resilience; 3. formation of productive coping; 4. activation of adaptive personal resources Group psychocorrection, cognitive-behavioral psychotherapy, mindfulness
The tasks of the psychoeducational module were: stimulation of formation of an active personal position of family caregivers on overcoming and prevention of consequences of mental disorder, development of responsibility for their social behavior and learning adequate coping strategies to use according to the presence of mental pathology in a close family member, restoring social contacts and improving psycho-emotional and social-communicative competence.
The main assets of the psychoeducational module of medical-psychological support system for FC of patients with EMD are:
1. awareness-raising about mental illness that facilitates the timely recognition and management of certain painful manifestations and symptoms in a family member;
2. receiving psychosocial support when group is a constant source of support and, at the same time, a therapeutic environment in which FC can develop adequate communication skills and coping behaviors in sheltered, emotionally secure conditions;
3. meeting the psychological needs of communication, group acceptance, belonging;
4. creation of favorable basis for further medical-psychological interventions.
Psychoeducation as a group method of work, belongs to the so-called educational type, in which sessions are built on the principle of a thematic educational seminar with elements of social and behavioral training. Psychoeducation is focused on providing information, including a list of specific issues discussed in the group.
Participants are provided with information on specific issues (for example, on the pathogenesis of the disease and features of drug therapy) with the simultaneous monitoring of the psycho-emotional state of FC.
Group sessions help support FC and patients at a stable level of functioning; help FC and their "significant others" better understand the nature and features of mental illness and how it affects the patient and family members; contribute to the recognition of life stressors that can provoke exacerbations; help to properly change family functioning during worsening of the patient's condition.
Thus, on the basis of in-depth study of socio-psy-chological features of family functioning as a socio-therapeutic environment, we offered an integrative system of psychoeducation and psychocorrection aimed at normalization of psycho-emotional state, development of adaptive behaviors of family caregivers, enhancement of their empathy and affiliation resource, creation of favorable conditions for activation of personal resources and adaptive capacity of patients with EMD.
By structure, the system of medical-psychological support for families of patients with EMD included three main stages: a) psychodiagnostic; b) complex psychocorrection; c) monitoring of psychological changes. The targets of medical-psychological support system were: dramatic or negative type of attitude towards the patient, pathological psycho-emotional state (psycho-emotional overload), maladaptive behavioral patterns, individual psychological factors reducing the communicative resource, insufficient development of social intelligence.
83 FC of patients with EMD (two psychocorrection subgroups, SG1 - family caregivers of patients with paranoid schizophrenia and SG2 - family caregiv-ers of patients with affective disorders) were involved in psycho-corrective measures. The control subgroups included 80 PP patients with EMD (CSG1 and CSG2), who did not participate in psychoeducational and psy-chocorrective activities.
The period of determining the effectiveness of developed medical-psychological support system was 6 months from the beginning. Effectiveness criteria were the dynamics of family burden on the scale of family burden assessment and the dynamics of quality of life indicators.
The effectiveness of proposed system of medical-psychological support was evaluated by psychological testing method (Caregiver Burden Inventory (CBI), 36-item Short Form Survey (SF-36). Significant reductions in the burden on the family were found, including
a decrease in severity of indicators on the scale of "behavioral problems", "stigma", "problems with psychiatric institutions", "influence on family" "dependence" with a simultaneous increase in indicators on the scales "accumulation of positive personal experience" and "positive aspects of relationships" in family caregivers of patients with EMD, who participated in psychoedu-cational and psychocorrective activities (P <0.001) (fig. 2).
30
26
25
20
15
10
20
12
21
18 18
14
13 13
16
Behaviora l
problems
■ SG1 □ CSG1 SG2 CSG2
20 26 12 18
18 21
13
14
13 16 5 8
25 25
20
5
17
11
10
18 18 17 17
10
22
18
16 16
14 14
Negative
symptom Stigma
14
Problems with
psychiatri Influence . Depende t ■, g the c on family nce
patient
institutio ns
20 17 17 10
25 25 18 14
10 17 10 12
11 18 14 16
Lesion
16 18 14 22
20
17
12
12
11
12
Accumula tion of positive personal experienc e
17 12 20 12
Positive aspects of relationsh ips
11 6 12 9
5
0
s
■ SG1 DCSG1 ■ SG2 ■ CSG2
Figure 2. Dynamics of family burden indicators in subgroups of family caregivers (CBI, scores)
In control subgroups of family caregivers of patients with EMD, positive dynamics wasn't identified. The study of quality of life in family caregivers of patients with EMD, who participated in psychoeducational and psychocorrective sessions, allowed to determine its increase in terms of physical and psychological functioning compared to the control subgroups (P <0.01).
Thus, a system of medical-psychological support for family caregivers of patients with endogenous mental disorders was developed, which included elements of psychoeducation and psychocorrection by methods of cognitive-behavioral psychotherapy; mindfulness-oriented cognitive therapy; psychological training; art therapy. This system needs further implementation and study of its effectiveness in decreasing family disadaptation in families, where a patient with endogenous mental disorder lives.
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THE RELATIONSHIP BETWEEN PECULIARITIES OF THE IMMUNITY AND CLINICAL SYMPTOMS IN EPISODIC PARANOID SCHIZOPHRENIA
Mikhailova I.
PhD, learding researcher
Moscow Research Institute of Psychiatry - Affiliated Office of National Medical Research Center of Psychiatry and Narcology, named V.P. Serbsky, The Ministry of health, Russia
Orlova V.
DMS, professor, chief researcher
Moscow Research Institute of Psychiatry - Affiliated Office of National Medical Research Center of Psychiatry and Narcology, named V.P. Serbsky, The Ministry of health, Russia
MinutkoV.
Doctor of Medical Sciences, Professor, Head of the Clinic Mental Health Clinic, Russia, Moscow
Simonova A.
DMS, professor of General medical practice chair, Moscow regional research institute (GBUZ MONICA) named M. F. Vladimirsky
Russia, Moscow
ВЗАИМОСВЯЗИ МЕЖДУ ОСОБЕННОСТЯМИ ИММУНИТЕТА И КЛИНИЧЕСКИМИ ПАРАМЕТРАМИ ПРИСТУПООБРАЗНОЙ ПАРАНОИДНОЙ ШИЗОФРЕНИИ
Михайлова И.И.
канд.мед.н., ведущий научный сотрудник «Московский институт психиатрии» - филиал ФГБУ «Национальный Медицинский Исследовательский Центр Психиатрии и Наркологии»
Минздрава России им. В.П. Сербского, Россия, Москва
Орлова В.А. д.мед.наук, профессор «Московский институт психиатрии» - филиал ФГБУ «Национальный Медицинский Исследовательский Центр Психиатрии и Наркологии»
Минздрава России им. В.П. Сербского, Россия, Москва
Минутко В.Л.
д.мед.наук, профессор, руководитель клиники Клиника «Психическое здоровье», Россия, Москва
Симонова А.В.
д.мед.наук, профессор кафедры общей врачебной практики, Московский областной научно- исследовательский институт (ГБУЗ МОНИКИ)
им. М.Ф.Владимирского, Россия, Москва.
Abstract
For the aim to investigate the systemic relationships between the tension of the different immunity components (cellular, humoral and phagocytic ones) and clinical features of episodic paranoid schizophrenia 47 patients (25 patients with F20.01-02 and 22 - with F20.03) were studied. For the symptoms assessment BPRS rating was used. The 21 parameters of nonspecific immunity status and the specific one - the Ig M and nuclear Ig G to herpes virus group (herpes simplex virus types 1 and 2, cytomegalovirus, Epstein-Barr virus) concentration in the blood serum were investigated.
