Rehabilitation, readaptation and resocialization of mentally ill patients. Rehabilitation of mentally ill patients is a federal program. For the family as a whole

Rehabilitation of mentally ill people has its own characteristics, which are associated primarily with the fact that with mental illness, like no other, social connections and relationships are seriously disrupted. Rehabilitation of mental patients is understood as restoring the preservation of the individual and social value of patients, their personal and social status. The basis of all rehabilitation measures, all methods of influence is an appeal to the patient’s personality. Rehabilitation is both a goal - restoration or preservation of the status of an individual, a process and a method of approaching a sick person.

Social rehabilitation is a system of measures aimed at returning patients to a socially useful life.

All rehabilitation measures should be aimed at involving the patient himself in the treatment and recovery process. It is impossible to rehabilitate a patient without his active participation in this process. This principle of rehabilitation of mentally ill people is called the principle of partnership according to Kabanov.

Rehabilitation influences must be diverse and versatile - this is the second principle of rehabilitation. There are psychological, professional, family, everyday, cultural, educational and other spheres of rehabilitation.

The dialectical unity of socio-psychological and biological methods in overcoming the disease is the third principle of rehabilitation: biological methods of treatment, socio- and psychotherapy, rehabilitation should be carried out in combination.

The fourth principle of rehabilitation - the principle of gradual transition - boils down to the fact that all rehabilitation effects should gradually increase and often switch from one to another.

The main objective of treatment-activating regimens is to prevent the development of hospitalism and create opportunities for successful readaptation of patients in an outpatient setting. There are four main modes: protective - the patient's constant stay in bed and requires medical personnel to constantly monitor him; sparing complete freedom in the department, but it is prohibited to enter the hospital territory without accompanied by staff; activating providing patients with maximum freedom in the department; organization of full employment, patients are provided the right to independently leave the hospital department and a regime of partial hospitalization, treatment of them in some cases in a day hospital, in others - in a night dispensary.

Social rehabilitation measures should be carried out in stages.

The first stage is restorative therapy to prevent the formation of a personality defect.

The second stage is readaptation of various psychosocial influences on the patient.

The third stage is the possible more complete restoration of the patient’s rights in society, the creation of optimal relationships with others, and the provision of assistance in everyday life and work.

53. Rehabilitation after a somatic illness.

Psychological rehabilitation is designed to solve a wide range of problems of psychological assistance to persons with disabilities, and, above all, such as:

1. Normalization of mental state.

2. Restoration of impaired lost mental functions.

3. Harmonization of the self-image with the current social and personal situation: injury, disability, etc.

4. Assisting in establishing constructive relationships with reference individuals and groups, etc.

Thus, the goal of psychological rehabilitation is to restore mental health and effective social behavior

Restoring psychological and social adaptation after a stroke

Here there is a pronounced motor and speech deficit, pain syndrome, and loss of social status. Such patients need a warm psychological climate, the creation of which should largely be facilitated by explanatory conversations conducted with family and friends by a psychologist.

In the process of work, psychological correction of the following disorders of higher mental functions occurs: cognitive impairment; emotional-volitional disorders; accounts; gnosis, often spatial disorientation in space.

Psychological rehabilitation after abortion

Termination of pregnancy is not only a great physical, but also a psychological stress for any woman. A course of psychological rehabilitation after an abortion is recommended for all women, without exception.

The main method of treatment is psychotherapeutic sessions, which it is advisable for a woman to attend for at least 1-2 months. As a rule, they give fairly quick positive results: a woman gets rid of difficult thoughts, becomes more sociable, open to the world around her, stops avoiding sexual contact with her partner, and begins to make plans for the future.

Psychological rehabilitation in cancer treatment

There is an opinion in the world that cancer is incurable. This is why many people, upon hearing this diagnosis, panic. That is why psychological rehabilitation of cancer patients is primarily aimed at changing public opinion.

The first rule of psychological rehabilitation for cancer patients is to make the person want to fight it.

The psychological rehabilitation of a person with this disease largely depends on the close people who surround him or her. Relatives should discuss the problem and give examples of other people who were eventually cured of cancer. A sick person should communicate with such people as often as possible.

If a person strives for his recovery and does everything necessary to achieve it, then a positive result will not be long in coming.

Rehabilitation after a heart attack.

The goal of using psychotherapy in the treatment of myocardial infarction is the psychological adaptation of patients and orientation towards an active lifestyle.

The rehabilitation program includes components such as psychoregulation based on absent-minded hypnosis, ideomotor training, adaptation training, and auto-training and self-regulation techniques are also used.

A significant aspect is social rehabilitation. Rehabilitation in social terms is the restoration of human social activity as a subject of public life; in medical terms, this is the elimination of health disorders as the cause of impaired legal capacity.

In tertiary psychoprophylaxis The social rehabilitation of patients is of primary importance.

An important role in the development of psychoprophylaxis is played by improving the structure and increasing the number of various psychiatric, psychotherapeutic and psychological institutions, especially those close to the population (day hospitals, night clinics, psychoneurological and psychotherapeutic offices at clinics, crisis centers, psychological services by telephone, etc.) , as well as improving methods of diagnosis and treatment of patients with initial, mild forms of mental disorders.

Rehabilitation is a system of state, socio-economic, medical, professional, pedagogical, psychological and other measures aimed at preventing the development of pathological processes leading to temporary or permanent loss of ability to work, at the effective and early return of sick and disabled people (children and adults) to society and to socially useful work. Rehabilitation is a complex process, as a result of which the patient develops an active attitude towards the impairment of his health and restores a positive perception of life, family and society. Rehabilitation includes prevention, treatment, adaptation to life and work after illness, and above all, a personal approach to the sick person.

Currently, it is customary to distinguish between medical, professional and social rehabilitation. For mental illnesses, rehabilitation has its own characteristics, primarily related to the fact that with them, like no other illnesses, serious disturbances occur in the personality, its social connections and relationships, loss of social skills, including due to a long stay in the clinic and hospitalism developing in patients. Rehabilitation of mentally ill people is understood as their resocialization, restoration or preservation of individual and social value, their personal and social status. As a priority direction of the reforms carried out in foreign psychiatry in recent years, the active implementation of which is being prepared in our country, the transition from an exclusively medical model of care to a biopsychosocial model has been chosen.

Abroad, the problem of resocialization of mentally ill people became acute in the late 1970s and early 1980s, when, under the influence of the antipsychiatric movement, a huge number of patients were discharged and psychiatric hospitals were closed. Discharged patients, unable to lead an independent life and provide for themselves economically, joined the ranks of the homeless and unemployed. They needed not only psychiatric help, but also social protection, financial support, and training for lost labor and communication skills.

With the close cooperation of psychiatric and social services, existing through government funding, public and charitable foundations, an extensive social rehabilitation system has been formed in many European countries, aimed at the gradual reintegration of mentally ill people into society. The objectives of the institutions included in it are to provide mentally ill people with a temporary place of residence, train and instill in them the skills necessary in everyday life, and improve their social and labor adaptability. For this purpose, special hostels and hotels were created in which patients not only live, are provided with psychiatric observation, but also receive assistance in professional and labor adaptation. The employment of patients in normal production conditions, but with constant supervision by psychiatrists and social workers, is becoming increasingly common. Unfortunately, this form largely depends on employers.

Reform of the organization of psychiatric care in no way means an immediate reduction in the bed capacity of psychiatric hospitals. But in the future this is inevitable. An alternative to specialized psychiatric hospitals may be the creation of short-stay units for acute psychotic patients within the structure of large multidisciplinary hospitals. World experience shows that moving patients with mental disorders outside the walls of psychiatric institutions helps not only to reduce cases of hospitalization, but also their social adaptation. This will improve the quality of examination and treatment. The maintenance of people with mental disorders in the new conditions will not differ from other contingents, their social rejection due to stigmatization will decrease. In connection with the specialization of city multidisciplinary hospitals, it seems possible to expand the network of specialized psychosomatic and somatopsychiatric departments.

The main link should be the outpatient service. According to V.Syastrebov, a significant part of the currently hospitalized patients (up to 40%) could do without hospitalization. In recent years, due to the general deterioration of the economic situation, the closure of some state-owned enterprises and the emergence of unemployment, the rehabilitation of mentally ill people has also become a difficult task. Rehabilitation institutions previously provided by the state - medical and labor workshops, artels and industries where disabled people could work - have fallen into disrepair. Due to insufficient material resources, vocational training programs for the mentally retarded in auxiliary schools and boarding schools are being curtailed, and the vocational schools that accepted their graduates are closing.

Under the current conditions, the need has emerged to find new ways to organize social and labor adaptation for the mentally ill and mentally retarded. In modern socio-economic conditions, only the development of out-of-hospital care can help achieve the main goal - the true rehabilitation of patients, their adaptation to difficult living conditions. At the same time, not only the strategy, but also the tactics of providing assistance change. There is a need for a transition from a predominantly medical model to a multiprofessional model - a team method), when specialists from different fields work with the patient at the same time. This is a psychiatrist, psychotherapist, psychologist, psychiatric nurse, social worker, activation therapist, etc. Only in this case there is an integrated approach to treating the patient, which takes into account all his problems - medical, social, psychological, etc.

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Rehabilitation of mental patients

Rehabilitation of mental patients, believes M.M. Kabanov, has its own characteristics in contrast to “general medical rehabilitation” and, first of all, involves “resocialization”, i.e. emphasis on the patient’s personality as a whole and on the social aspects of his problems.

According to M.M. Kabanov, the principles of rehabilitation of mental and drug addiction patients are virtually identical. In the field of narcology, they have their own characteristics, determined by the clinical picture of the drug addiction disease, personal deviations, social status of the patients, etc.

M.M. Kabanov identified three stages of rehabilitation of mentally ill patients, which, taking into account the nosological specifics, are also used in narcology:
1) rehabilitation therapy aimed at preventing the formation of mental defects and disabilities; at this stage, pharmacotherapy, physiotherapy, exercise therapy, environmental treatment, employment, etc. are used;

2) readaptation, which pursues the goal of adapting the patient at one level or another to environmental conditions; psychosocial influence predominates, including stimulation of social activity by various methods (occupational therapy, vocational training, educational work, work with relatives, etc.;

3) rehabilitation itself - restoration of the individual and social value of the patient; household and work arrangements, participation in the work of AA, NA, etc. is recommended. At the same time, the author believes that patients with alcoholism do not need the second stage of rehabilitation (in the absence of pronounced alcohol degradation).

The emphasis of rehabilitation measures is transferred to the social and labor spheres of activity.

The system of rehabilitation of patients with impaired mental health proposed by M.M. Kabanov is based on such provisions as complexity, multidisciplinarity, integrity (“connectedness”) of system-forming elements, dynamic connection between the components of the system, hierarchy “horizontally” and “vertically”.

At the same time, the components included in the system have relative autonomy. In particular, each stage of rehabilitation is autonomous, its implementation leads to the achievement of a specific goal and, naturally, improves the patient’s condition. However, only completion of the third stage can lead to stable remission or recovery.

But the third stage cannot be implemented without the first two. Consequently, the well-known postulate “The whole is greater than the sum of its parts” well illustrates the understanding of rehabilitation as a complex medical and social system, which is effective only in the case of complex and stage-by-stage functioning of all its subsystems.

V.T. Kondrashenko, A.F. Skugarevsky (1983) believe that rehabilitation is a dynamic system of interconnected components that cannot be reduced either to individual methods (psychotherapy, occupational therapy) or to the final goal (employment, etc.).

Rehabilitation of patients with alcoholism is a system of medical, psychological and social measures carried out after the onset of the disease, as well as aimed at its prevention. Based on the works of M.M. Kabanov, they believe that the basic principles of rehabilitation of patients with alcoholism should include: partnership (doctor - patient), versatility (diversity, complexity of activities), unity of biological and psycho-social methods of influence, gradation (transitivity, transition from inpatient to outpatient treatment, etc.).

V.I. Mikhailov (1997) believes that social disadaptation of patients with hashish drug addiction requires the use of a complex of social rehabilitation measures - medical, educational, labor, etc. This approach promotes readaptation and stable resocialization of patients.

According to T.N. Dudko (1998, 1999), rehabilitation in narcology is a complex medical-psycho-social system aimed at restoring the physical, mental and spiritual health of a drug addict, his personal and social status, the ability to fully function in society without drug use. PAS that cause painful addiction and negative social consequences.

T.N. Dudko, V.E. Pelipas, V.I. Revenko (1998) believe that rehabilitation is not only the liberation of the patient from painful dependence on psychoactive substances, but also his return to the family, to society, where he is again capable perform their socially useful functions - family member, work collective, citizen, etc.

The authors identified the following principles of medical and social rehabilitation: voluntariness, complexity (teamwork), unity of medical-biological and psycho-social methods of rehabilitation, continuity (phasing), trust and partnership, long-term, integrative, rejection of paternalism.

In 2000, under the leadership of N.N. Ivanets, a group of employees of the Research Institute of Narcology of the Ministry of Health of the Russian Federation (M.G. Tsetlin, V.E. Pelipas, T.N. Dudko, Yu.V. Valentik, etc.) created a concept for the rehabilitation of patients suffering from drug addiction in healthcare institutions.

It is noted that rehabilitation in narcology is a system of medical, psychological, educational, educational, social, legal, and labor measures aimed at the personal readaptation of patients, their resocialization and reintegration into society, subject to the cessation of the use of addictive substances.

The goal of rehabilitation is the restoration (or formation) of the patient’s normative personal and social status based on the disclosure and development of his intellectual, moral, emotional, and creative potential. The task of rehabilitation is determined by the need to achieve its ultimate goal, taking into account the most important aspects of the patient’s life situation - medical, personal, social - through its active directed reorganization.

The following principles have been identified as rehabilitation principles:
1) voluntary participation of the patient in the treatment and rehabilitation process (TRP);
2) accessibility and openness of rehabilitation institutions;
3) trust and partnership;
4) unity of socio-psychological and medical-biological methods of targeted influence;
5) diversity and individualization of forms (models) of rehabilitation measures.

Stages of rehabilitation - adaptation, integration (inclusion of the patient in full into the continued program), stabilization (keeping the patient in the program, preparation for the transition to the next stage of the medical treatment, i.e., transfer to another specialized institution or discharge home).

Conditions or requirements for the implementation of PRP:
a) the patient’s refusal to use surfactants;
b) personal responsibility for the successful implementation of the LRP;
c) reliance on positive, personally significant social values ​​for the patient;
d) ensuring legal and organizational regulation of PRP;
e) creation of a single “team” of specialists in a rehabilitation institution.

In 2001, a concept for the rehabilitation of minors who abuse psychoactive substances was developed for the Ministry of Education of the Russian Federation (T.N. Dudko, Yu.V. Valentik, N.V. Vostroknutov, L.A. Kotelnikova, A.A. Gerish, under the general leadership of G.N. Trostanetskaya).

It is considered as a system of educational, psychological, educational, medical, social, legal, labor measures aimed at stopping the use of psychoactive substances, the formation of an anti-drug attitude of the individual, his resocialization and reintegration into society.

The goal of rehabilitation is the return of minors to life in society based on the restoration of physical and mental health, cessation of psychoactive substances, restoration (or formation) of their normative personal and social status.

The treatment and rehabilitation process involves the use of a number of basic principles:
1) the patient’s voluntary consent to participate in rehabilitation activities;
2) stopping taking surfactants;
3) confidentiality;
4) systematic rehabilitation measures based on the use of a “team” approach;
5) stages of rehabilitation measures;
6) positive orientation of rehabilitation measures;
7) responsibility;
8) inclusion of key significant others in rehabilitation;
9) reorganization of the living environment and the formation of a rehabilitation environment;
10) differentiated approach to the rehabilitation of various groups of minors;
11) social and personal support after discharge from a rehabilitation institution.

The following stages of rehabilitation are identified:
a) initial (entry into the program) - lasting up to 2 months;
b) expanded (main stage) - up to 6-8 months;
c) final (exit from the program) - up to 2-3 months.

In addition, a preventive block of measures is proposed, implemented after completion of the main rehabilitation program. It is aimed at creating social support, preventing breakdowns and relapses of the disease.

P.D. Shabanov, O.Yu. Shtakelberg (2000), summarizing the main focus of various rehabilitation programs for drug addicts, believe that their goal is the readaptation and resocialization of the drug addict and his family.

Rehabilitation centers must satisfy a number of the following conditions:
a) be sufficiently remote from large cities and industrial complexes;
b) observe stages in the implementation of rehabilitation programs;
c) adhere to certain principles of the protective regime: fairness, rigor, caring, integration into the patient’s problems, constant work with the patient’s family.

Yu.V. Valentik (2001) considers rehabilitation in narcology as a “systemic and multidimensional process.” In his opinion, the main components of such a process are medical rehabilitation (tertiary prevention), psychological (personal), including spiritual rehabilitation, and social rehabilitation.

The goal of rehabilitation is the restoration (or formation) of the patient’s normative personal and social status, allowing reintegration (integration) into society, based on the cessation of the use of psychoactive substances.

The author identifies the following principles of rehabilitation: voluntariness (consent); cessation of drug use (PAS); responsibility; reliance on social values ​​and norms; phasing; consistency and teamwork; differentiation.

O.V. Zykov, A.D. Artemchuk et al. (2001) talk about a single “rehabilitation space” (RP), “representing a territorial system of institutions, services, departmental structures, public initiatives and organizations taking part in the prevention of social maladjustment of minors and their rehabilitation."

The purpose of the RP is the positive socialization of minors; the basic principles of RP are client-centrism, consistency, system development, integrity of efforts, starting from the client, his family, etc. and to legislation and state social policy.

V.V. Batishchev, N.V. Negerish (2001) attach great importance to the creation of a treatment and rehabilitation environment in medical institutions for drug addiction patients, ensuring the safety and security of those interested in treatment from patients who are not motivated for treatment, prone to aggressive, antisocial and provocative forms of behavior.

According to their opinion, the rehabilitation environment in the department, the psychotherapy and rehabilitation program are created and function primarily in the interests of those patients who strive for recovery, the fastest possible adaptation and resocialization. Each department specialist feels like a member of a team solving common problems.

In practical terms, rehabilitation is a unified system of “interaction of components to obtain a fixed beneficial result” (P.K. Anokhin, 1971). Therefore, rehabilitation is considered as a medical and social system that has its own principles, stages and patterns of functioning (Bertalanffy, 1960; M.M. Kabanov, 1971; I.V. Blauberg, E.G. Yudin, 1973; Yu.V. Valentik, 1997; T.N.Dudko, 1997, etc.).

Narcology, separated from psychiatry in 1975, at the same time remains predominantly a psychiatric discipline, forming a single whole with it in clinical, social and legal terms. Over the more than twenty-five-year period of its “independent” existence, domestic narcology has developed into a developed specialized service with a powerful network of treatment and preventive institutions, qualified personnel potential, a professional training system, etc.

At the same time, a rapprochement between narcology and social sciences (psychology, pedagogy, sociology, social philosophy, etc.), determined by practice, emerged. The tendency to create our own conceptual apparatus and professional terminology is being actively implemented.

The accumulated knowledge today allows us to formulate and systematize the basic principles of rehabilitation of drug addicts, using a systematic approach to the analysis of this problem as one of the methods of modern scientific research.

Rehabilitation in psychiatry

Occupational therapypatientschainedTobed (Otis Historical Archives Nat"l Museum of Health & Medicine )

Rehabilitation is a set of measures aimed at full or partial restoration of the personality of a sick person, his social and labor status. In contrast to treatment aimed at eliminating and reducing the manifestations of the disease, rehabilitation is aimed at strengthening, strengthening, and growing healthy aspects of the patient’s personality, compensating for mental functions lost during illness at the expense of its intact part. Rehabilitation is described as “an intervention that attempts to discover and develop the capabilities of patients - as opposed to treatment that directly addresses the failure of patients” (Martin (1959). Thus, rehabilitation is a wonderful complement and completion of drug and psychotherapeutic treatment.

The basic principles of rehabilitation originated in ancient times; even ancient Greek and Roman doctors suggested walking, rhetoric exercises, caring for plants, etc. as healing methods. Subsequently, the medieval perception of madness not so much as a mental illness, but as obsession, a kind of mental “perversion,” placed him under lock and key, depriving him of any hope of cure. However, placing mentally ill people in monasteries often provided them with a kind of “rehabilitative” way of life: a measured, clearly scheduled regimen, physical labor, etc. The era of enlightenment brought a new assessment of mental illness - the concept of insanity arose as a consequence of an incorrect, immoral lifestyle. Accordingly, treatment begins to use such methods as limiting unwanted contacts, strict regimen, reading properly selected literature, and physical labor. Later, the concepts of degeneration and moral insanity helped to consolidate the view of mental illness as manifestations of “immorality,” “lack of will,” and “weakness.” To some extent, this point of view continues today; many of our patients hear the same advice from friends and relatives: “Pull yourself together,” “Get this nonsense out of your head,” “Stop being idle and everything will pass,” etc. . However, all these methods, while outwardly resembling some rehabilitation measures, had a completely different focus: not the restoration of lost functions and adaptation due to the intact aspects of the psyche, but some kind of “re-education” of the patient.

Modern rehabilitation does not aim to “educate the patient” or treat him. She taps into the remaining parts of the psyche to teach patients how to use their strengths. Rehabilitation in psychiatry consists of three areas:

· Medical rehabilitation – treatment of residual manifestations of the disease, maintaining and strengthening remission, maintaining the patient’s disposition to comply with doctor’s recommendations and continue treatment (including with the help of psychoeducational programs).

· Vocational rehabilitation – restoration of working capacity.

· Social rehabilitation – restoration of the patient’s individual and social value, his self-esteem, relationships with the environment, the fight against stigmatization.

Psychoeducation occupies a special place in the rehabilitation of the mentally ill. It represents a comprehensive system of psychotherapeutic work with the patient and his relatives, including teaching them the basics of psychiatric literacy and methods of coping with problems caused by mental illness.

How to accept a family member's illness? How to understand the patient? How to withstand severe trials? How to help a loved one? What help can the family provide in the treatment and rehabilitation of the sick person? How to decide to see a doctor and what to ask him?

This article is intended to help people with mental illness and their loved ones cope with the everyday problems that arise when living together.The most common problems encountered in such families are discussed, as well as some effective approaches to everyday communication.The advice that will be given may be useful to anyone who has encountered schizophrenia or another serious mental disorder in their family.

General psychiatry Tiganov A.S. (ed.)

Its immediate tasks include: medical rehabilitation aimed at achieving the maximum possible clinical compensation, relieving the manifestations of the disease and preventing its undesirable consequences or reducing them; vocational rehabilitation - returning the patient’s ability to participate in socially useful work and independent life support; social rehabilitation - restoration of the individual and social value of the patient.

Brief historical sketch. The need for a humane attitude towards the mentally ill and maintaining their social status was recognized by scientists back in ancient times. Thus, Caelius Aurelian (IV - V centuries AD)1 in his instructions recommended benevolent, gentle treatment of the mentally ill, and prescribed walks, pleasant conversations, reading, theater and exercises in rhetoric for those recovering. But a real shift in the corresponding psychiatric views occurred later, only in the 18th century. At the origins of the movement for “no-restraint” of the mentally ill and the creation of conditions worthy of human beings was the French doctor Philippe Pinel. In England, the ideas of a humane attitude towards the mentally ill were promoted by W. Tuke, who was the first to organize an asylum for them with free maintenance (1792). Psychiatry owes the actual abolition of restraint measures to J. Conolly (1839). With the active participation of J. Esquirol, in 1838 the first legislative act protecting the rights and interests of the mentally ill appeared in France. Similar laws by the middle of the 18th century. were adopted in other European countries.

In Russia, for centuries, the holy fools, the wretched and those who have lost their minds found refuge in monasteries. Only under Peter I did the first special homes for the mentally ill (dolgauzes) appear. Later, during the reign of Catherine II, the Charter of the Orders of Public Charity was published, which included asylums for the insane, which prescribed a philanthropic attitude towards their inhabitants.

At the end of the 18th - beginning of the 19th centuries. Family patronage began to occupy a significant place in the care of the mentally ill (especially developed in areas adjacent to large hospitals), in which elements of the rehabilitation of patients in its modern content became more obvious. Finally, in 1900 V.M. Bekhterev, for the first time in Russia, opens a neuropsychiatric department at the St. Petersburg Clinic for Mental Illnesses with free access for those recovering, which expanded the possibilities for their integration into ordinary life. New hospitals are beginning to provide specially equipped rooms for various crafts. The latter served both the purposes of healing (occupational therapy) and partly for the entertainment of patients. Colonies were organized for chronically ill patients, which were located mainly in rural areas, so that patients who retained the ability to work could engage in agricultural work (gardening, field work, cattle breeding, etc.). So, in 1873, a large colony opened near Novgorod, and in 1881 - in the village of Pokrovsko-Meshcherskoye near Moscow. In some colonies, the “open door” system began to be practiced. Already at that time V.I. Yakovenko, observing the negative consequences of a patient’s long stay in a hospital and isolation from society, was one of the first Russian psychiatrists to express the idea of ​​​​the need to decentralize psychiatric care. He proposed a project for establishing a network of small hospitals, “pushed into the very thick of everyday life.” Later, P.P. Kashchenko, head of the hospital in Nizhny Novgorod (1898-1920), turned it into an exemplary medical institution. The presence of workshops and vegetable gardens at the hospital allowed patients to participate in the labor process as much as possible. He also organized a colony for the mentally ill, following a Western model, where he widely practiced a system of family patronage.

But the most active dissemination and implementation of the ideas of “non-restraint” in Russia is associated with the name of S.S. Korsakov and representatives of his school, to whom domestic psychiatry owes the fact that the main approaches to in-hospital rehabilitation of mentally ill patients, relevant to this day, were formed in Russia back at the beginning of our century. S.S. Korsakov, being the initiator and leader of the zemstvo and city construction of psychiatric institutions, abolished all measures of physical restraint for patients (straitjackets, isolators, bars on windows, etc.). His interests also included issues of protecting the civil rights of the mentally ill, conducting forensic psychiatric examinations, disseminating psychiatric knowledge among the population and preventing mental disorders.

The followers of S.S. Korsakov, V.P. Serbsky and P.B. Gannushkin, did a lot to develop legislation on the mentally ill, resolve issues of the right to charity and support, sanity, legal capacity and ability to work, i.e. a complex of legal problems, without considering which the real resocialization of mentally ill people is impossible. Subsequently, the zemstvo psychiatrist T.A. Geyer (one of the initiators of the creation of the Institute for the Examination of Working Capacity and Labor Organization of Disabled Persons) created the clinical foundations of medical labor examination, employment of the mentally ill, out-of-hospital care, psychotherapy and occupational therapy - all that later became part of the concept "social and labor rehabilitation".

Although the foundations of domestic social psychiatry were laid back in the zemstvo period, their implementation on a state scale occurred only in the 20-30s of the 20th century, marked not only by the reconstruction of existing psychiatric hospitals, but also by the organization in our country of out-of-hospital psychiatric services (psychoneurological offices , dispensaries) and the formation of a system of social and labor placement for patients.

Thanks to the development of a network of psychoneurological dispensaries, it became possible to provide outpatient treatment for mentally ill patients and reduce the length of their hospital stay. It has become possible to provide them with qualified medical and social care throughout their lives, maintaining continuity of treatment and rehabilitation measures between the hospital and the dispensary. The need for social isolation of patients and separation from everyday life has disappeared. Observation of outpatient populations has made adjustments to scientific ideas about the dynamics of mental illnesses, showing that over the course of most of them many patients do not require hospitalization, remain in society and, given favorable conditions, can remain able to work for a long time.

The basis for social and labor rehabilitation of mentally ill patients has become day hospitals for mental health problems, occupational therapy rooms and occupational therapy workshops. Occupational therapy is also widely carried out in psychiatric hospitals themselves, where in almost every department, during the hours provided for by the internal regulations, patients perform the simplest work (assembling small parts of various devices, making artificial flowers, toys, gluing together packaging boxes, etc.). Some patients perform outdoor work on the hospital premises. In hospitals with a well-organized treatment and rehabilitation process, the organization of such activities occupies a fairly large place along with cultural therapy (watching films, using the library, etc.). However, this “in-hospital” rehabilitation at the present stage of social development could not satisfy either psychiatrists or patients, and in almost all countries, rehabilitation measures began to be carried out outside psychiatric institutions on a higher technical basis.

An important stimulus for the introduction of such occupational therapy was the spread of the ideas of sociotherapy. The origins of the latter were the German psychiatrist N. Simon (1927), who considered the inclusion of a mentally ill person in collective work activity as a powerful factor in stimulating his social activity and overcoming the phenomena of pathological psychosocial adaptation to an unfavorable hospital environment. The system he proposed, in a slightly modified form, became widely known in the post-war years under the name “occupational therapy”; "industrial therapy", or "industrial rehabilitation" (industrial therapy, industrial rehabilitation). Its starting point was group work in medical workshops in conditions close to actual production conditions, but then such therapy was transferred to agricultural and industrial enterprises. This trend became especially characteristic of post-war psychiatry.

The possibilities of such rehabilitation have increased significantly after the introduction of effective antipsychotic drugs into clinical practice, which made it possible to achieve not only an improvement in the condition of many patients, but also their discharge from the hospital with transfer to maintenance therapy. Therefore, the development of industrial rehabilitation in our country reached its greatest “flourishing” in the 70-80s. In the psychiatric literature of those years, its various organizational forms were widely covered and convincing data were provided about its high effectiveness [Melekhov D.E., 1974; Kabanov M.M., 1978; Krasik E.D., 1981]. Not only various forms of labor readaptation have been developed, but also corresponding medical and psychological influences on the patient during its implementation.

In our country, in large agricultural and industrial regions, special rehabilitation centers dealt with these issues. Let us briefly look at the characteristics of the most typical of them.

In 1973, a post-hospital rehabilitation center was created in the Odessa region, operating on the basis of an agricultural enterprise. The relationship with the state farm, built on the principle of self-financing, provided for the provision of patients with a comfortable hostel (where they were fully self-service), food in the canteen and work. Qualified medical care was provided to patients by the rehabilitation service of the Odessa Psychiatric Hospital. Thus, psychosocial (sociotherapeutic) and biological methods of influence were comprehensively used in the rehabilitation process. The patients performed field work, were employed on a livestock farm, and in specialized workshops for processing agricultural products. The rehabilitation process was carried out in stages, starting with the formation of professional skills and ending with rational employment on the state farm. The center was designed primarily for patients with chronic and ongoing forms of mental illness, as well as those suffering from frequent relapses. Among them, people with a long history of illness (from 10 to 25 years), long-term (more than 5-10 years) continuous stay in a psychiatric hospital or frequent rehospitalizations predominated. Observations of patients in this center showed that as a result of rehabilitation measures, the frequency of exacerbations was significantly reduced, the duration of interictal intervals increased, productive symptoms were mitigated, and manifestations of the defect were compensated. About 60% of patients fully mastered production skills, the rest mastered them partially [Maryanchik R.Ya., 1977].

Rehabilitation centers provided significant financial benefits to healthcare by reducing the length of stay of patients in the hospital, the cost of the products they produced, and the profits received from their sale. But such labor rehabilitation also pursued a more important goal - to make possible the discharge, out-of-hospital existence and self-sufficiency of disabled patients who had been in psychiatric hospitals for a long time, including colonial ones. At the same time, the tasks were set to restore lost connections with relatives and friends, revive forgotten skills of correct behavior and self-care, as well as the emotionality of patients (with the additional use of cultural therapy, physical therapy, etc.). Industrial rehabilitation has become widespread in Kaluga [Lifshits A.E., Arzamastsev Yu.N., 1978] and Tomsk [Krasik E.D. et al., 1981].

It should be noted that the organization of industrial rehabilitation provided significant advantages to patients compared to work in traditional occupational therapy workshops. Such workshops were considered an intermediate link on the way to employing patients in a special workshop or in regular production. But work in medical labor workshops was not work in the legal sense, since the patients were not accrued work experience, work books were not created, and they received monetary compensation instead of wages. They were not given a certificate of incapacity for work ("sick leave"), and were not provided with paid leave. They thus remained in the position of patients of a medical institution and it was not possible to talk about their true compensation. The social status of patients in working conditions at an ordinary industrial enterprise changed radically.

In Kaluga Regional Psychiatric Hospital No. 1 in 1973, on the basis of medical workshops, a special turbine plant workshop was opened, which became not only a center for labor and social rehabilitation, but also a place for industrial training of patients in an industrial enterprise.

The workshop employed people with disabilities of groups I and II due to mental illness, as well as patients who did not have disabilities, but due to their condition could not work in normal production conditions. Patients were enrolled in the staff of a special workshop and performed relevant production operations. Compliance with working conditions, correct use of patients' labor, implementation of sanitary and hygienic measures and monitoring of the mental state of patients was carried out by specialists from the psychiatric hospital. All this made it possible in many cases to achieve an increase in the level of social adaptation. Production tasks were selected for patients in strict accordance with the objectives of rehabilitation. The plant administration provided patients with one meal and payment for treatment, and provided them with various types of labor of varying complexity, from simple cardboard work to assembling electrical circuits for radio equipment. Since the workshop was located on the territory of the hospital, patients had the opportunity to work in it while still in the hospital. In turn, patients employed in the workshop, if their condition worsened or were temporarily incapacitated, could be transferred to the hospital for day or full hospitalization. Patients employed in the workshop were equal in their rights to factory workers (they received wages, bonuses for fulfilling the plan, and had the full range of social services provided by the factory). Moreover, being part of a trade union organization, patients were sometimes actively involved in social work, which contributed to the restoration of real social skills and connections. If there was no need for daily psychiatric observation, patients could be transferred to regular production.

A similar organization of industrial rehabilitation, but on a larger scale, was carried out in the Tomsk region with the active participation of employees of the Department of Psychiatry of the Tomsk Medical Institute and the Tomsk Regional Psychiatric Hospital. In special premises, workshops of some Tomsk industrial enterprises were set up, where patients were provided with types of labor of varying complexity (including work on machines). This allowed patients not only to receive fairly good payment for the products produced, but also to make a significant contribution to the overall efficiency of the relevant production. The latter had enormous psychotherapeutic significance for patients, not to mention the fact that long-term ill patients with severe mental defects, who had been a “burden” for the family for many years, turned into active members and, to some extent, “breadwinners.” Some patients were employed in individually created conditions directly at industrial enterprises in Tomsk or on suburban state farms. Industrial rehabilitation was carried out in several stages. The first of them, lasting from 2 months to 2 years, was a period of temporary employment, when patients, being in partial hospitalization, had the opportunity to gradually expand their social and professional activity. They were provided with systematic comprehensive assistance by medical and social workers, psychologists of special rehabilitation teams. The overall beneficial effect of rehabilitation was achieved in 70% of patients who had previously been almost completely socially and professionally maladjusted.

There was extensive experience in the rehabilitation of mentally ill patients in St. Petersburg, where the organizers of this case were specialists from the Psychoneurological Institute named after. V.M. Bekhterev of the Ministry of Health of the Russian Federation [Kabanov M.M., 1978].

The development of rehabilitation programs has made it necessary to create some new organizational structures. Thus, for patients who did not have a family or had lost one, special dormitories were organized, the way of life in which was as close as possible to the usual. Here, patients who had previously spent a long time in a chronic psychiatric hospital could gradually restore lost skills of everyday life. Such hostels played the role of an intermediate link between the hospital and real life and were often organized at a psychiatric hospital. Staying in such hostels was one of the most important stages in the process of resocialization of patients. However, this form has not yet received development adequate to its significance.

Despite the fact that industrial rehabilitation was the optimal form of returning patients to socially useful work, it was not widespread in the country. Even in the 70-80s, it covered only a small part of those in need (about 8-10% of the total number of disabled people). There were not enough places in the special workshops. The types of labor offered in them, mostly low-skilled, did not always take into account previous professional employment and practically excluded the participation in rehabilitation programs of persons who had previously been engaged in mental activity. The rates of removal of the disability group and return to normal production remained low. Most of the patients had lifelong disabilities and, at best, could only work in specially created production conditions and under medical supervision. Considering the unstable performance of mentally ill people, the need for a gentle individual approach to them, and the prejudiced attitude of work collectives, enterprise administrations, in turn, showed no interest in expanding the network of special workshops or hiring mentally ill people into regular production.

In foreign countries, the problem of resocialization of mentally ill people, which also became acute in the late 70s and early 80s, was to a certain extent associated with the antipsychiatric movement, when the process of so-called deinstitutionalization began - removing patients from the walls of psychiatric hospitals and closing them. Discharged patients, unable to lead an independent life and provide for themselves economically, joined the ranks of the homeless and unemployed. They needed not only psychiatric help, but also social protection and financial support, training for lost labor and communication skills.

With the close cooperation of psychiatric and social services, existing through government funding, public and charitable foundations, an extensive social rehabilitation system has been formed in many European countries, aimed at the gradual reintegration of mentally ill people into society. The objectives of the institutions included in it are to provide mentally ill people with a temporary place of residence, train and instill in them the skills necessary in everyday life, and improve their social and labor adaptability. For this purpose, special hostels, hotels, so-called halfway houses were created, in which patients not only live, are provided with psychiatric observation, but also receive assistance in professional and labor advancement.

Patients discharged from hospital in some countries have the opportunity to enter out-patient clinics and rehabilitation centers with a limited period of stay. So, in France it does not exceed 18 months. By the end of this period, the skills acquired by the patient are assessed and his ability to return to work on a general basis or be limited to the level of medical and labor institutions is determined. The employment of patients in normal production conditions, but with constant supervision by psychiatrists and social workers, is becoming increasingly common. Unfortunately, this form largely depends on employers.

According to the unanimous opinion of psychiatrists, the vast majority of patients in need of rehabilitation are patients with schizophrenia. Special training programs were used for them (social skill training, communication training; occupational training), aimed at achieving autonomy in the patient’s lifestyle, improving his social connections and preventing complete isolation (which is most important for patients with schizophrenia). In rehabilitation, an individualized approach is of particular importance, taking into account the type and severity of the patient’s dysfunction (lack of initiative and emotions, social and cognitive defect). Relatively recently, special computer programs based on the type of dialogue have appeared. They are designed to train concentration and other cognitive functions and can be used by patients independently. The most common training methods aimed at correcting the patient’s social behavior (token economy programs; social skill training strategies) use the strategy of copying correct behavior in everyday life: in addition to correcting the emotional-volitional and cognitive disorders inherent in patients with schizophrenia, they help develop the skills necessary to solve everyday problems. maintaining independent living skills, including the use of social benefits and financial resources.

Thus, modern rehabilitation approaches are aimed primarily at the patient’s personality, the development of lost skills and the activation of compensatory mechanisms. If the degree of insolvency of the patient does not allow him to function without outside help, then the state and society take care of him. With regard to the implementation of rehabilitation programs, even economically developed countries with a high standard of living experience significant difficulties associated with financial support. Following a period of optimism and unfulfilled hopes for the rapid implementation of rehabilitation programs, a more balanced understanding of the real state of affairs has come. It became clear that the rehabilitation of mentally ill people is not a program limited to one time or another, but a process that should begin at the stage of initial manifestations of the disease and continue almost throughout life, which requires a lot of effort on the part of society in general and health authorities in particular. Insufficient financial support, partly due to the diversion of material resources to solve more pressing issues (in particular, the fight against AIDS), led to the curtailment of rehabilitation programs in many countries, as a result of which many mentally ill people began to return to psychiatric hospitals.

In Russia, in recent years, due to the general deterioration of the economic situation, the closure of some state-owned enterprises and the emergence of unemployment, the rehabilitation of mentally ill people has also become a difficult task. Rehabilitation institutions that were previously provided by the state - medical and labor 362 - have fallen into disrepair.

workshops, artels and industries that used the labor of disabled people. Due to insufficient material resources, vocational training programs for the mentally retarded in auxiliary schools and boarding schools are being curtailed, and the vocational schools that accepted their graduates are closing. Medical and social services focused on the resocialization of mentally ill people have not yet received their development. At the same time, enterprises and psychosocial assistance organizations operating on a commercial basis, without any connection with government institutions (hospitals and dispensaries), have emerged in the country. But due to the high cost of the services they provide, they remain practically inaccessible to the majority of low-income mentally ill people.

Under the current conditions, the need has emerged to find new ways to organize social and labor adaptation for the mentally ill and mentally retarded. One of the most promising areas seems to be the formation of non-state charitable foundations, clubs for social support of mentally ill people, associations of their relatives and other public organizations interested in their social reintegration. Created as one of the first in 1991 with the active participation of a group of psychotherapists, the patients themselves and their relatives, the Human Soul charity foundation implements a set of programs aimed at increasing social competence and social rehabilitation of mentally ill disabled people. Within the framework of one of them, the “Moscow Club Fund,” patients have the opportunity to improve their professional skills and gain work experience in the field of office work, catering and leisure, employment and establishing contacts with employers, which they need for subsequent employment in regular jobs. The foundation provides patients with financial support and free meals in a charity cafeteria. A special program dedicated to the further development of the system of non-governmental organizations provides for the training of regional representatives of this movement in Russia.