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SYCHOSOCIAL REHABILITATION: THE INDIVIDUAL REHABILITATION PROGRAM
By Enrico Conti *
*Neuro - psychiatrist, Coo.S.S.E.L. Cooperative.
Evaluation Theoretical Approach Operative Model
To reintegrate in society people with mental disabilities, in particular persons with a long history of chronic dysfunction is certainly a very difficult road to pursue requiring much time and effort to realise. The starting point in moving towards better living is psychosocial rehabilitation without which every tentative effort to restore to society the psychologically and mentally disabled would conclude with a sure unsuccessful.
For the post eight years the Coo.S.S.E.L. Social Co-operative has been engaged in four Residential Communities for female patients (Rausei "A", Rausei "B", "Pellaro 3" and Sala di Mosorrofa); offering a psychosocial Rehabilitation is structured in such a way so as to identify three cardinal points:
- Evaluation of the presenting disabilities for each patient
- A systemic relationship theoretical model approach;
- An operative model based on Mark Spivak Social Competency Approach to psychosocial rehabilitation and personalised treatment programs.
EVALUATION
Let us look more closely and analytically at how treatment interventions are structured and realised with the disabled.
Illustrations on the various phases of the overall work plan are shown which crystallise towards the construction of the individual rehabilitation program, personalised resocialitation and eventually whenever possible to reintegration within the family of origin or in less restrictive environments.
To implement its rehabilitation program the Coo.S.S.E.L. Social Co-operative utilises instruments and programs elaborated by its staff. These are periodically reviewed, examined closely and corrections made whenever necessary.
The professional technical staff, co-ordinators and rehabilitation workers complete a personal folder on each patient.
Various daily management schemes, and of course the individualised treatment program comprise part of the folder. Before effecting any rehabilitation strategy each worker fills out an evaluation checklist of disability for each patient haved on what is internationally recognised in the field as "assessment". This includes verification of the grade and intensity of the presented deficits.
Application of this methodology is necessary to ensure that rehabilitation interventions on behalf of the Coo.S.S.E.L. Social Co-operative fall between two extremes within which assessment is applied. That is, the vision that any activity with the disabled is rehabilitating is not privileged, nor is the idea that only extremely specific programs with rigid procedures codified by complex rules are the only ones that foster improvement. An attempt is made to avoid schematising a patients residue abilities and consequent stigmatisation of behaviour in such a manner as to entrap him/her and offer the illusion of predicting rehabilitation outcome. Treatment interventions in structured on socialising interactions between workers and patients and not on various instruments of measurement, nor on the absolute realisation of the rehabilitation program.
Engaging the patient successfully in socialising interactions is in effect one element of the evaluation process, and a measure in understanding his/her response to the program. In this way, treatment intervention can be modified, modulated flexibly and based on the patients realistic needs.
The individualised treatment program and evaluation of the possible interventions to be made requires that specific areas of diagnosis be identified. In accordance with the "Disability Assessment Schedule" of the World Health Organisation, the following areas of intervention have been identified:
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Personal Hygiene and personal well-being;
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Behaviour;
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Autonomy and relationship;
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Material conditions of existence;
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Social and Family Support.
THEORETICAL APPROACHES
The theoretical approaches to rehabilitation adopted in the Residential Communities by the technical multi-disciplinary team and workers of the Coo.S.S.E.L. follows a model oriented towards systems theory. To rehabilitate means to act upon in equal measure on the patients relationships activate adequate emotional distance, influence not only the patients behaviour but also that of others whit whom the patient interacts. Intervention is not circumscribed to the disabled but penetrates the entire personal field and context within which the rehabilitation process takes place.
There is no distinctly rigid difference between daily living and rehabilitation, but a diversification of the instruments applied to treatment and subsequent levels of intervention. In this way, a new light is shed on understanding the interpersonal dynamics and relationships, between the patients group and community living.
In turn this fosters significant possibility that rigid social roles and dysfunctional transactions can be positively influenced leading to adequate behavioural and cognitive functioning.
OPERATIVE MODEL
The operative model is based on socially competent behaviours. Accent is placed on the importance of social competencies and their relationships. For Mark Spivak, originator of the model, this requires an analysis of the pathways through which the patient reaches chronic disability. A strong role is given to the persons of personal and social failures in contributing to a progressive distancing from his/her personal and social articulation. The consequence is the a adoption of a dysfunctional role pushing the patient towards isolation, segregation and impairment in his/her social role taking skills in his/her social environment; final out come can be expulsion and or eventually institutionalisation. Mark Spivak describes the pathways to the development of chronic stabilised desocialisation through reciprocal distancing as a circular spiral; towards which the patient moved with consequent regression and isolation in respects to the deviant behavioural expectations of those significant others with whom the patient interacts.
This means that rehabilitation needs to impose its objectives of allowing patients acquire socially competent behaviours that will permit him/her to act and interact with success in his/her daily living environment. Thus, the prescription of rehabilitation modalities must be based upon an analysis of the life space of the individual from which a diagnosis can be made. Five life areas have been found to be generally comprehensive:
The Coo.S.S.E.L. Co-operative has a general program of rehabilitation that leads to restitution to society the mentally disabled.
At the very base of the pathways to rehabilitation is the formulation of a personalised program for each single patient living in the Residential Communities. In fact, it is not possible to imagine that any rehabilitation strategy constructed by the Co-operative personnel is the same for all patients. An exception however regards the theoretical approach and the base methodology guidelines; these interventions are constructed in a differentiated manner.
The patients are divided into primary groups, between 6-8 patients with social competency as homogeneous as possible; decreasing capabilities for each primary group.
Patients are not assigned randomly to each primary group, not all pas from one primary group to another as if these represented steps of a latter to be scaled arising from the abyss of chronic disability. No, the patients are grouped according to competency, computed progress, attitude and personal motivation. The patient is placed at the very centre of the Rehabilitation process and not the contrary. A final objective of the Rehabilitation program is complete recovery, foster Reintegration in his/her family of origin, or whenever possible activate resocialitation that lends to more autonomy with and or without social support.
Naturally, the entire rehabilitation process realised in the Residential Communities by the Coo.S.S.E.L. workers is guided by direct supervision.
Supervision, for Coo.S.S.E.L., should not be considered as the learning of specific technical skills, but rather as a specific personal education, therefore it represents a variable of crucial importance for the success of all rehabilitation strategies. Supervisor and rehabilitation worker need to decide on what hypotheses need to be tested.
Supervision, in the Residential Communities, is to foster maturation in the rehabilitation worker who can in turn carry-out independently psycho-social rehabilitation whit success, as our results demonstrate.
It can be concluded that these results have been obtained, our experience on the field demonstrates clearly the facts. A process has been initiated which is certainly destined to create substantial changes in operative approaches in "Service to People". The international literature alongside our experience confirm that this trend can not be denied. That a need for autonomy, flexibility, operative immediateness organisational efficacy and efficient transactions whit a capacity to gather changes is a short time whiten the rehabilitation field is strongly needed.
References:
AA. VV.: Atti del convegno “La riabilitazione psichiatrica tra realtà e aspettative: linee d’intervento”, Edizioni Coo.S.S.E.L. Reggio Calabria, 1991.
AA. VV.: Atti del Convegno “Gli itinerari della riabilitazione psichiatrica: dalla lungodegenza alla nuova cittadinanza”, Edizioni Coo.S.S.E.L. Reggio Calabria, 1992.
Siani R., Siciliani O. e Burti L.: “Strategie di psicoterapia e riabilitazione”, Feltrinelli Editore Milano, 1990.
Spivak M.: “Atti dei seminari sulla riabilitazione psicosociale”, Edizioni Coo.S.S.E.L. Reggio Calabria, 1993-1995.
Spivak M.: “Introduzione alla riabilitazione sociale: teoria, tecnologia e metodi di intervento”, in “Rivista Sperimentale di Freniatria”, 111, 1977, pag. 522-574.
Spivak M.: “A conceptual framework for the structuring of the living of psychiatric patients in the community”, in “Community Mental Health Journal”, 10, 1974, pp. 345-350.
Spivak M.: “Towards a systematisation of social competency approach to rehabilitation: theory and definitions”, in “The Israel Annals of Psychiatry and Related Disciplines”, 15, 1977, pp. 289-299.
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