Rehabilitation of the Mentally Ill is Improvement of Their Quality of Life: Theoretical & Methodological Aspects
This report was researched and drafted by Professor M.M. Kabanov of the St. Petersburg V.M. Bekhterev Psychoneurological Research Institute.
The notion “rehabilitation” has for a long time been used in jurisprudence. In medicine it became widely used in the second half of the twentieth century. However, only very few people know the fact that already in medieval Spain, in the epoch of the Holy Inquisition, the monks of one of the monasteries in the environs of Salamanca began, when giving care to the mentally ill, to use measures that can be classified today, to a considerable extent, as rehabilitation. Even the term “rehabilitation” was in use at that time. Earlier than that, since the 13th century, on the territory of today’s Belgium, there existed, and is likely still to exist now, a small village of Guilles which has been a permanent residence for the mentally ill, where, owing to their relatively liberal way of life, they serve themselves and realize in practice the elements of modern rehabilitation positions. Specialists know very well the work of such predecessors of the rehabilitation trend in psychiatry as Ph.Pinel, D.B.Tuke and D.Conolly.
The concept of rehabilitation of ill and disabled persons in its modern interpretation received its further development in the years of World War II in Anglo-Saxon countries, though, earlier than that, at the beginning of the 20th century, H.Simon in Germany and P.Sivadon in France had managed to demonstrate in their hospitals the effectiveness of the rehabilitation approach to the mentally ill. In Russia, among those who can be considered as the precursors of the rehabilitation trend in psychiatry were I . F.Ruehl, A.U.Fraese and N.N.Bazhenov. A considerable contribution to this field was also made by the Dutch psychiatrist and sociologist A.Querido who, at the 1st Congress of the World Association for Social Psychiatry in London in 1964 emphasized the fact that the borders between prevention, treatment and rehabilitation were very relative. Especially worth noting is the significance for rehabilitation of the work of the British psychiatrists and psychotherapists, creators of the concept of “therapeutic community”, T.Main and M.Jones, as well as of the founder and first President of the World Association for Social Psychiatry J.Bierer. In 1967, on the eve of “the Prague spring”, there was held a meeting of the ministers of public health care and social security of a number of East- European countries, called “socialist” at that time. T h e meeting adopted a resolution that gave a comprehensive definition of rehabilitation as a dynamic system of interdependent components (public, socio-economic, medical, psychological, pedagogical and other ones) aimed at the prevention of the development of pathologic processes causing a temporary or a stable loss of working capacity, at an effective and early return of ill and disabled persons to the society and socially useful work. In other words, rehabilitation, regarded as the ultimate goal, is a complete or partial restoration (preservation) of the personal and social status of an ill person or of one in a pre-morbid state. This definition which we entirely agree with has been assumed as a basis in the theoretical, methodological and practical developments of the concept of psychosocial rehabilitation at the V.M.Bekhterev Institute for over thirty last years. These developments have been used in various ways, according to the specificity of diseases, at different clinical departments of the Institute. They have been used in the treatment of endogenic psychoses, including schizophrenia and depressive states; of epileps y, alcoholism and other types of drug addiction; of neuroses and other borderline states; of vascular pathology of the brain; in geriatric and adolescent psychiatry.
It is worth noting, and we have repeatedly mentioned it in our publications, that up to now there is no common understanding of the essence of the many- sided dynamic process of rehabilitation. A tendency to reductionism and simplification of the comprehensive notion “rehabilitation” prevails in the assessment of this process which is closely connected with the quality of life of a human being (1, 2).
Most often rehabilitation is understood as a restoration of a person’s rights and a rational arrangement of his/her job placement and everyday life. These aspects of rehabilitation are of great significance, of course; however, they do not determine entirely its essence and ultimate goal. One can (and should) give ill or disabled persons legal rights (for instance, an opportunity to consult a lawyer or to go to the law), help them to find a job (to do so, however, is often quite a problem under the condition of the economic crisis in many countries, including Russia), help them to arrange their everyday life (for instance, to improve their housing conditions, which is also a problem due to the above reason); how-e v e r, having done so, one can, nevertheless, fail to achieve the ultimate goal -to restore their personal and social status, i.e. to improve their quality of life to such an extent that the improvement could be felt, above all, by ill and disabled s u fficiently considered, without taking into consideration personality and environmental factors, job placement can lead to a dismal end – to the patient’s neglect of compliance and, as a consequence, to a disease relapse, including the so-called self-destructive behavior (suicide, alcoholism, drug addiction, etc.).
There also exist other, rather widespread, interpretations of rehabilitation. For instance, some people understand rehabilitation as an optimization of traditional treatment, or more often, as a continuation of treatment in the form of after-care using physiotherapeutic and balneal measures and therapeutic physical training (which in itself is very important). A great number of specialists, “rehabilitologists”1, con-fuse rehabilitation with such measure as the use of an ill (disabled) person’s remaining working capacity. In our understanding, however, rehabilitation is not only the ultimate goal (restoration of the patient’s status), but also a complex systemic process with its psychophysiological and sociopsychological parameters. In our opinion, rehabilitation is, above all, a method of approach to an ill person or to one in a pre-morbid state.
In 1969-1972 we developed four basic principles of rehabilitation of the mentally ill; these principles, however, can be applied to rehabilitation of patients with any disease, taking into account its specificity. The first principle is the partnership of the therapist and the patient that provides for an appeal to the patient’s personality. It should be emphasized that to realize this principle it is absolutely necessary to attain in the “doctor-patient” system a confiding contact and a “tandem” mutual assistance. The second principle is the diversity of efforts, measures and interventions directed not only at the patient’s organ-ism, and not so much at it, as at different aspects of the patient’s psychosocial functioning (i.e. his/her attitude to his/her own “ego”; to his/her disease; to his/her future, for instance, to the pattern of expected results of treatment; to his/her family, social environment, work or studies; to the society at large). It is evident that in the process of realizing this principle the patient needs not so much biological treatment as the competent aid of psychologists, social workers and, in some cases, pedagogues, lawyers and clergymen. The third principle of rehabilitation is the unity (unity, not identity!) of biological and psychosocial interventions directed at the organism as well as at the personality and the patient’s environment. Finally, the fourth principle of rehabilitation is a step-by-step character and transitivity of various measures and interventions, both biological (medical, physiotherapeutic, etc) and, especially, psychosocial ones. The latter include, above all, psychotherapy in different forms, such as, for instance, group and family psychotherapy, the so-called milieu therapy, occupational therapy and work therapy. Usually they distinguish three stages of rehabilitation – medical, psychological and social (professional) ones. We prefer to interpret the initial stage of rehabilitation as restorative treatment, the second stage – as readaptation, and the third, final, stage, aimed at attaining the ultimate goal – as r e h abilitation in the proper (direct) sense of the word (the first two stages being a sort of preparation to it).
Each stage of rehabilitation has its specific order of priority (and correlation) of biological and psychosocial interventions. Usually the priority of biological interventions decreases from stage to stage, while psychosocial interventions, on the contrary, replace them or co-exist with them. At the third, final, stage of rehabilitation especial importance is attached to changing (normalizing) the attitude of the society towards the disease (or, which would be more correct to say, to an ill person) and, hence, to the problems of compliance and stigmatization.
In the assessment of the quality of life of the mentally ill the great, and often decisive, significance of the problem of stigmatization (labeling) and, hence, destigmatization is beyond any doubt. It goes without saying that in different cultures with their specific traditions the attitude of the society to “lunatics” is far from being unambiguous. One has only to recall the attitude of the society to the so-called “yurodivies” (“God’s people”) in medieval Russia or the attitude of local population to Siberian shamans or to African sorcerers (the latter, by the way, were recruited by Albert Schweitzer to work in his clinic in Gabon).
In the 21st century, against a background of continued progress in space exploration, in the development of means of communication (the Internet), biology, medicine (cloning and genetic engineering, for instance), etc., it is sad to see obvious and veiled quackery in science, especially in human science, which reveals a deep spiritual crisis of the society and its search of often inadequate ways of solving behavioral, cognitive and emotional problems. It would be appropriate to remind of the growth of influence of religious sectarianism and national chauvinism which, like sorcery and quackery in medicine and psychology, cause the deterioration of mental health of the population. At this point cause and consequence often trade places.
Justly, the World Health Organization (WHO), understanding very well the above problems, decided to devote World Health Day 2001 (7th April) to mental health. Alas, there is still a great number of high-ranking officials (the so-called VIPs) responsible for the welfare of their countries who do not realize in full measure the approaching danger of the growing avalanche of manifest and latent mental disorders, including pathologically aggressive and self-destructive behavior. In this connection, quality of life investigations become today extremely significant in all areas of public health care (Shevchenko Yu.L., Medical Gazette, ## 53-54, 2000).
There is a considerable number of contemporary investigations carried out, for instance, by the research fellows of the V.M.Bekhterev Institute that illustrate the necessity to give more attention to mental health care not only, and not so much, on the part of psychiatrists, as on the part of other specialists. Many human problems (ecological, demographic, economical and others) that are most topical today are closely connected with the mental health of the population. They are also closely connected with the intellectual, emotional and ethical state of mankind. Mental health care today is one of the most urgent national problems affecting, among other factors, national security. It can be solved only by uniting the efforts of many countries. The World Health Organization (WHO) and a number of other international organizations (the World Psychiatric Association, the World Mental Health Association, the World Association for Social Psychiatry, the World Association for Psychosocial Rehabilitation, etc.) have for a long time been trying to make governmental circles understand more distinctly the tragic situation arising in the field of mental health of the population of our planet. Unfortunately, for the time being, the results of their appeals are but modest. It is quite possible that the year 2001, the first year of the new millennium, declared by the WHO the Mental Health Year will help to improve today’s situation when the mental health of the entire population of the Earth deteriorates catastrophically. It becomes more and more obvious that the motto of modern public health care and medicine should be the popular expression “It is important not only to add years to life, but also life to years”.
LIST OF REFERENCES:
1. Kabanov M.M. “Rehabilitation of the Mentally Ill”. Second
Edition. Leningrad, 1985.
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