Common Problems in Psychosocial Rehabilitation

The International Journal of Psychosocial Rehabilitation

Dr. Hitesh C. Sheth
Medical Officer & Psychaitrist
Hospital For Mental Health
Baroda, India
drdivinescorpio@yahoo.co.in

Citation:
Sheth, H.C. (2005). Common Problems in Psychosocial Rehabilitation.
International Journal of Psychosocial Rehabilitation. 10(1), 53.60.

Contact:
Dr Hitesh C Sheth, 202 Aashrayadeep ApartmentGautamnagar Society, Alwa Naka, Manjalpur, Baroda, Gujarat, India .

Abstract
Many of the problems in rehabilitation in the third world countries arise due to the lack of financial resources. The lack of financial resources causes difficulty in regular continuation of medication and subsequent relapse of the illness. The lack of job opportunities also interferes with the rehabilitation. Sometimes societal insensitivity and expressed emotions in a family are responsible for the reemergence of the psychiatric symptoms. While in some cases long term stay in hospital also interferes in rehabilitation, because long-term hospital stay may produce the secondary negative symptoms in a patient. The difficulties also arise due to the lack of trained staff and psychiatrists. The burn out problem cause rapid turn over of the staff and the staff have to be train again. The bureaucratic hurdles also slow down the processes of the rehabilitation. The field of rehabilitation is also preferred less by the Psychiatrists.

Key Words: Rehabilitation, Financial Problems, Burn Out.

Introduction:
Psychosocial rehabilitation is a term used to describe services that aim to restore the patient’s ability to function in the community. It not only includes the medical and psychosocial treatment but also include ways to foster social interaction, to promote independent living, and to encourage vocational performance (Cook et al.1996). Unlike past now psychosocial rehabilitation aims to integrate patients back into the community rather than segregating them in separate facilities. The goal of psychiatric rehabilitation is to teach skills and provide community supports so that the individuals with mental disabilities can function in social, vocational, educational and familial roles with the least amount of supervision from the helping professionals. The professionals must involve families in treatment planning and implementation. So rehabilitation is labor intensive and person-to-person venture. The developing countries are having dearth of financial resources, which causes the tremendous difficulties in rehabilitation of the patients. A study of the status of the mental hospitals commissioned by the National Human Rights Commission revealed gross inadequacies in all aspects of care, clinical services and rehabilitation (National Human Right Commission, 1999). I would like to discuss common problems, which one face while rehabilitation of patients in the developing countries, which are having scare financial resources. The developed countries may have the different set of problems. But some of the problems like bureaucratic hurdles, uncooperative attitudes of relatives and societal insensitivity may be seen in both, developing as well as the developed countries.

Irregular Follow Up due to financial problems:
Most of the patients coming into government institute in the developing countries are from lower socio-economic strata and most of them are daily wage earners. They are living hand to mouth existence. Even the patient from “well to do families” faces financial problems when some member in families develops mental illness. And when earning member of family develops illness, the problem becomes more acute. A survey of an urban community in southern India, served by four state-run general hospitals with psychiatric services and a large psychiatric institution, found that a third of people with schizophrenia had never accessed any treatment (Padmavati et al, 1998). Even after these individuals and their families were offered treatment, a third of them continued in their untreated state (Srinivasan et al, 2001).

The processes of rehabilitation start with medication. But due to lack of money they cannot come for regular follow-up. They cannot afford bus-fare or train-fare. Sometimes illness of earning member of families ensures that they don’t even have money to eat, let alone for bus-fare or train-fare. Sometimes hospital has to arrange for bus fare or train fare from the poor patient’s fund. So patients cannot come to take medication regularly. They cannot take medicine form outside because cost of medicine is high. And medicines have to continue for long time or in some cases for the lifetime. This leads to frequent relapses of illness.

The other major reason for discontinuation of the medicines is necessity of taking medicine for long time and in some case for a lifetime. And some times side effects of medication are responsible for the discontinuation of medicines.

Lack of medicines in governmental Institute:
Sometimes government institutes in developing countries lacks even the basic medicines. Patient’s condition may be stable on long-term depot preparation (e.g. Fluphenazine Deconate) and suddenly the stock of injection is finished. They cannot purchase the medicine form outside because cost of medicine is high. And medicines have to continue for a long time or in some cases for the lifetime. They are reluctant to purchase medicines from the outside because they believe that despite taking the medicines patients are not going to improve completely. They believe that schizophrenia like diabetes and hypertension is controllable but not curable. But in the case of hypertension and diabetes the patients are mostly productive. They know that in the most of cases the patients are not going to earn money in the future, so they are reluctant to purchase the medicine from outside the hospital.

Difficulties in a Vocational Rehabilitation:
Sometimes the patients want to come to day care center for vocational training. But due to lack of money, he is unable to do so. Even the governments in the developing countries cannot arrange for the transport because of the lack of the fund, so the patients cannot come regularly.

Sometimes patient may manage to have bus fare for attending daycare activities. But sometimes the hospitals don’t have the materials for the daycare activities; e.g. patients may be doing tailoring work but sometimes there is no stock of the clothes. Even number of the vocational training centers is inadequate. Some private day care centers are there but cost is prohibitive. There are no buyers for the materials produced in rehabilitation center, because most of the time the materials produced by the patients are not as good as the material produced by the professionals. The only buyer is the government, but the governments in the developing countries have limited requirements and limited purchasing capacity.

Lack of Job Opportunities:
In developing countries with a limited job opportunities and burgeoning population (e.g. population of India is more than one billion), even educated people don’t get job, so it is very difficult for the mentally ill patients to get job. Irony is some person develops the mental illness because they are not having job. The occupational functioning of men is still crucial in the Indian setting, where the man is largely the main breadwinner. Unemployment and underachievement act as threats to his social status. Compounding this situation, the social security system in India does not consider patients with schizophrenia as its beneficiaries. In India mental illness are not yet eligible for any welfare measures (Thara et al, 2004). Employment provides not only a monetary recompense but also ‘latent’ benefits — non-financial gains to the worker which include social identity and status; social contacts and support; a means of structuring and occupying time; activity and involvement; and a sense of personal achievement (Shepherd, 1989). People with mental illness are sensitive to the negative effects of unemployment and the loss of structure, purpose and identity, which it brings (Rowland & Perkins, 1988). Studies show a clear interest in work and employment activities among users of psychiatric services, with up to 90% of users wishing to go into (or back to) work (Grove, 1999). There is a tendency for mental health professionals and others to underestimate the capacities and skills of their clients and to over-estimate the risk to employers (Boardman J, et al.2003). Satisfactory working life may reduce the need for clinical support, but such support should remain available and be tailored where possible to the constraints of the individual's working life (Secker et al, 2002). Unemployment is associated with physical ill health, including premature death (Wilson & Walker, 1993; Bartley, 1994).    Social isolation is often particularly problematic for people who experience mental health problems, and work is effective in increasing social networks (Boardman J, 2003). Lack of job and ensuing financial crisis causes tremendous stress which cause relapse of symptoms, which in turn lead to difficulty in psychosocial rehabilitation.

Hospital as a Shelter:
In developing countries, where poverty is widespread, many relatives of the patient don’t want to take discharge, even when patients have improved completely. This happens in case in which patient is admitted in open ward along with his relative. Sometimes when doctor asked them to take discharge, then relatives and patients describe fake symptoms. And when one cross check with the attendants and nursing staffs the said symptoms are absent. The reason for not taking discharge is they may not be having food, shelter or job. Sometimes patient with substance addiction may develop with friendship with other patient having addiction. They may exchange address of secret places where drug is freely available. Some relatives are reluctant to take discharge because they feared that patient may relapsed at home and they again have to borrow the money to bring patient to the institute. All these things may interfere with rehabilitation, treatment and improvement of patients.

Hospital as a dumping site:
Many relatives of the patients are not interested in the treatment or rehabilitation of the patients. There main aim is to get patient admitted in institute and get rid of him. Although they are not at all at fault because treatment and rehabilitation of psychiatric patients is always difficult due to frequent exacerbations and relapses of the illness. So to get rid of a patient they may give wrong address of home or change the home after patient is admitted in the institute. Some times they give the wrong history and the wrong symptoms, which are not observed when patient is subsequently admitted in the institute.

The reasons why they want to dump patients are many. First, some families’ economic conditions are poor. So they cannot feed the patient. Second many families’ lives in small house, which has no room for the patient. Third, many patients though improve up to quite an extent are still unable to find a job. So they stay at the home throughout the day. The male members, when they go out for a work in daytime, don’t want to keep patient near female members. They fear that the patient might not be manageable by the females if he becomes aggressive or the patient may do sexual assault on the female members of the family. Fourth reason is social stigma attached to the mental illness. Family member fear that their sons, daughters, sisters and brothers may not be able to get good spouse because almost all knows the fact that mental illness is inheritable and no one wants see illness in their off springs. Besides this newly wed spouse may be unwilling to stay with mentally ill patient in the same house. Fifth reason is, in today world with breaking social support systems; many people want to live in a nuclear family. So even a patient who has completely improved and doing a job and earning, still many families are not willing to keep them in their house. Sixth reason is patient’s parents may be getting old so they are unable to take care of patients. Sometimes condition is so worse that when patient’ s parents wants to keep patient at home, then his other relatives (e.g. son) may threaten that he will expelled the parents along with the patient. Seventh, reason is, in some case husband and wife both are working, so there is no one to look after the patient at home and no one to give him timely dose of medication. Sometimes, even after patient is improved completely, he cannot be sent to his home because his parents might have passed away and no one is left behind to look after him.

So for all this reasons patient’s relative don’t come to take patients at home even after the patient has improved completely. So when despite of repeated reminders when patients’ relatives don’t come to take patient home, then hospital has to arrange for police escort and send patient to home via court order. Sometimes they refuse to obey court order saying that they are ready to undergo punishment but they will not take patient home at any cost. The amount of punishment according to ‘Indian Mental Health Act ‘ is two thousand rupees (40 dollars), which is ridiculously low. So they don’t obey court order.
So it causes difficulty in rehabilitation of patient in the society.

Expressed emotions and relapse:
Brown described five components of expressed emotion (Brown, 1985): emotional over involvement, critical comments, hostility, positive remarks and warmth. Sometimes over involvement, hostility and criticism within family may worsen patients. Sometimes parents are extremely close to the patient and they fulfill his each and every whims and his unreasonable demands. They may not restrain his undesirable behavior so patient illness may relapse. The Patients in high expressed emotion settings were more likely to relapse (56% compared with 17% for low expressed emotion). Also, there was a high relapse rate (68%) among those in the non-medicated high expressed emotion group, whereas there were no relapses at all in the medicated low expressed emotion group (Leff & Vaughn, 1985).

Sometimes after long hospitalization, when a patient returns home, his relatives treat him as an outsider. They may have established a family equilibrium without patient so when the patient returns this equilibrium is disturbed. They unconsciously treat the patient as alien. The patients continuously feel that he is unwanted. Subtle hostilities and criticism of patients, who although improved but having fragile defense mechanism may worsens patient illness. In some patients with schizophrenia who were living as part of an extended family accessed treatment less often, even when it was considered essential to do so. The families, when interviewed on the issue, replied that they were used to their relative’s illness and that other family members compensated for the person’s non-productivity. Once they had reached this equilibrium they did not want to disturb it by seeking treatment. (R thara et al, 2004.)

Problems of Hospitalization:
We know how damaging many of the traditional practices of the asylum were, even when they had been adopted for the best of motives. The official practices (such as the locking of doors, constant oppressive security, continual counting of people, cutlery, bed linen and so on) were bad enough, but far worse were the unofficial happenings – the beating up, the garroting, the use of padded cells and ECT as punishments, and the occasional killing (David.H, 1998). But there are problems from patient’s side also due to their inability to adjust in outside world.

There is one popular folk story according to which, there was a fisherwoman, who daily used to sleep amidst smell of fishes. One day while returning to her home, she lost the way. So she had to sleep in house of flower vendor. But she was sleepless through out the night. She found smell of flowerers irritating because she used to sleep in room with a fishy smell. However during next night she was able to have sound sleep in her familiar surroundings. Same thing happens to some mentally ill patients. When they are discharged in society they feel awkward, because they are used to the hospital routine environment. They feel at home in mental hospital. Many have developed friendship with the other patients. When they go outside, many of their friends are married and well settled doing job or business. The patients are unable to establish relationships and friendships again with them. They feel like the fish outside water. The feeling of emptiness and worthlessness, get exaggerated, when they see that their friends relatives and colleagues are well established in society. This act as a stressor and patient illness may relapse again. However this happens in only small numbers of patients, otherwise most of the patients don’t like the hospital stay and they are always eager to go back in a society.

Societal Insensitivity:
Many patients when returned to the society, face insults. The society keeps overt as well as covert discrimination with them. They don’t admit them in their friendship circle and other activities. So the patient becomes lonely and isolated. A recent report, based on responses from 556 UK users, shows that 70% have experienced discrimination in some form: 47% in   the workplace, 44% from general practitioners and 32% from other health professionals (Mental Health Foundation, 2000).   Manning & White (1995) reported that 90% of mental health professionals who had a family member with mental illness, frequently heard colleagues make "negative or disparaging remarks" about patients: the majority of these professionals stayed silent and did not disclose their relative's illness. Lefley (1987) reported UK employers' reluctance to hire someone with mental illness. Mansouri & Dowell (1989) report that stigma is a significant source of distress in, for example, people with severe enduring mental illness in a community-support programme, where it correlates with self-esteem. In cinema and television, mental illness is the substrate for comedy, more usually laughing at than laughing with the characters (Byrne, 1997). Negative attitudes to people with mental illness start at playschool and endure into early adulthood: one cohort confirmed the same prejudices on re-examination eight years later (Weiss, 1994). These add tremendous strain to already poorly compensated defense mechanisms of the patient and patient may worsen again.

Problems while rehabilitating patient with substance addiction:
Sometimes patient with substance addiction has to return in the same environment, because of lack of job opportunities (e.g. Rickshaw driver or taxi driver may have to stand on the same site with his same group of friends having addiction). When he returns to friend circle having addiction, he again relapses. Sometimes patient develops addiction because he doesn’t have job. The patient faces same problem, when he is discharge from the hospital, so he again develops addiction. So this may also interferes with rehabilitation of patients.

Burn out of hospital staff:
As stated earlier, rehabilitation is labor-intensive processes. The results are slow to come and relapses are frequent. The term burn-out has been used to conceptualize the long-term negative effect of such stress and includes emotional exhaustion, tendency to develop cynical and negative attitudes towards others and negative self-evaluation, especially regarding personal accomplishment at work (Maslach & Jackson, 1986). The daily work of continual confrontation of illness, sadness, suffering, fear and pain makes staff insensitive towards patients. Power relationships between patients living together in intimate and anxiety-provoking circumstances have the potential to become sexualized and to affect staff.   Staff finds it particularly challenging to handle these difficulties with sensitivity; they can contribute to poor outcome, characterized by treatment dropouts, lack of meaningful therapeutic relationships and acting-out behaviour (Sarah Davenport, 2002). Sometimes staff is unable to balance compassionate concern with dispassionate objectivity. A sense of futility and failure can begin to permeate their attitude and can set the stage for anger and frustration about their profession, their patients and themselves. Sometimes staff stops correcting the unacceptable behavior of patient as slowly insensitivity creeps in their behavior, without their own knowledge. This leads to rapid turn over of staff engaged in the rehabilitation. New staffs have to be trained again. The field of rehabilitation is preferred less by the psychiatrists.

Lack of staff and over burdened Staff:
The staffs of the hospitals are woefully overburdened in the developing countries. The ratio of staff to patients is rarely in accordance with law and requirement. There are now 37 mental hospitals in the country with a total bed strength of 18 024 (National Human Rights Commission, 1999). The beds are grossly inadequate in comparison to number of patients and population. In the developing country like India the psychiatrists have to manage the average OPD of 70 to 80 patients. Along with managing OPD they also have to do the administration work and management of staff. Along with this work sometimes there is deputation of psychiatrist at the remote places. So sometimes there is no psychiatrist to run the OPD, let alone to do the rehabilitation work. So the very little time is left for rehabilitation work and its supervision. The low salary in comparison to private practice make government job unattractive, so many posts of psychiatrist in the government hospitals are vacant. So the work of rehabilitation remains in a sorry state. Another major problem is brain drain of psychiatrists and nursing staff to developed countries, which provides better working conditions and higher salaries.

The bureaucratic hurdles:
The delay due to bureaucratic hurdles may slow the processes of rehabilitation; example is sometimes demand of seeds for plantation work is put before the monsoon but sometimes seeds arrived after the completion of monsoon. Sometimes due to procedural delay there is delay in procurement of medicines. And patients have to put on a medicine other than he was taking for many years. The patient may worsen on another molecule of medicine due to psychological so physiological reasons.

Sometimes the task is so frustrating that one feels that the processes of rehabilitation, rehabilitates no one except those involved in the work of rehabilitation.

Conclusion:
To sum up the matter, mental illnesses would assume gigantic proportion in coming years. And governments must deployed more resources to tackle the illnesses and rehabilitate the patients. The mental illnesses not only affect patients but also his kith and kin in financial and social ways. We must rehabilitate the patients and thus save them, because as one wise sage wrote, “ No one will be saved till all are saved.”

Bartley, M. (1994) Unemployment and ill health: understanding the relationships. Journal of Epidemiology and Community Health, 48, 333–337.

Boardman J, Groove B, Perkins R, Sheperd G, The British Journal of Psychiatry (2003) 182: 467-468

Brown, G. (1985) The discovery of expressed emotion: induction or deduction? In Expressed Emotion in Families (eds J. Leff & C. Vaughn), pp, 7–25. New York: Guilford Press.

Byrne, P. (1997) Psychiatric stigma: past, passing and to come. Journal of the Royal Society of Medicine, 90, 618–620.

Cook JA, Pickett SA, Razzano L, et al: Rehabilitation services for person with schizophrenia. Psychiatr Ann26; 97-104,1996

David, H(1998) ‘The story of mental Hospital’ fulborn:1858-1883, Free Associations

Grove, B. (1999) Mental health and employment. Shaping a new agenda. Journal of Mental Health, 8, 131—140

Leff, J. & Vaughn, C. (1985) ‘Expressed Emotion in Families’. New York: Guilford Press.

Lefley, H. P. (1987) Impact of mental illness in families of mental health professionals. Journal of Nervous and Mental Disease, 175, 613 -619.

Manning, C. & White, P.T. D. (1995) Attitudes of employers to the mentally ill. Psychiatric Bulletin, 19, 541 -543.

Mansouri, L. & Dowell, D. A. (1989) Perceptions of stigma among the long-term mentally ill. Psychosocial RehabilitationJournal, 13, 79-91.

Maslach, C. & Jackson, S. (1986) Maslach Burnout Inventory (2nd edn). Oxford: Oxford Psychologists Press.

Mental Health Foundation (2000) Pull Yourself Together: A Survey of the Stigma and Discrimination Faced by People Who Experience Mental Distress. London: Mental Health Foundation

National Human Rights Commission (1999), Quality Assurance in Mental Health – A Project of the National Human Rights Commission. New Delhi: National Institute of Mental Health and Neurosciences.

Padmavati, R., Rajkumar, S., & Srinviasan, T. N. (1998), Schizophrenic patients who were never treated – a study in an Indian urban community. Psychological Medicine, 28, Rowland, L. A. & Perkins, R. E. (1988) ‘You can't eat, drink or make love eight hours a day’. The value of work in psychiatry. Health Trends, 20, 75—79.

Secker, J., Membury, H., Grove, B., et al (2002) Recovering from illness or recovering your life? Implications of clinical versus social models of recovery from mental illness for employment support services. Disability and Society, 17, 4.

Shepherd, G. (1989) The value of work in the 1980s. Psychiatric Bulletin, 13, 231—233.

Srinivasan, T. N., Rajkumar, S. & Padmavati, R. (2001) Initiating care for untreated schizophrenia patients and results of one-year follow-up. International Journal of Social Psychiatry, 47, 73 –80.

Thara R.,Padmavati R.,Srinivasan T.N.,(2004) The British Journal of Psychiatry 184: 366-373

Weiss, M. F. (1994) Children's attitudes toward the mentally ill: an eight-year longitudinal follow-up. Psychological Reports, 74, 51–56.

Wilson, S. & Walker, G. (1993) Unemployment and health. A review. Public Health, 107, 153–162