My patient was 59 year old lady suffering from schizophrenia since 25 years. According to patient she had a happy married life in London, her husband died and she was brought to Pakistan due to her abnormal behavior and her son was also separated from her. Medical file reveals that after her husband’s death she had behavioral changes for which she was consulted to psychiatrist and diagnosed with schizophrenia. She was forcefully brought to Karwan-e-Hayat 3 years back due to violent behavior. Since then she is there, presently she is experiencing social isolation as she stayed in her room most of the time, refuses to participate is day care activities and verbalizes that “I like to be alone, don’t want to meet anyone I have nobody to share my feelings, people here can’t help me, everybody think I am mad”. I observed her hesitation with people around her weather they are patients, staff or doctors. However one typical observation was that when I forced her to participate in activity she refuses twice but third time she participated by silently doing the task and went quietly. I noticed that she was facing difficulty in understanding but she didn’t ask for any clarification and continued. Reflecting upon the scenario I was motivated to work on something that can help to manage her social isolation. Reviewing through literature I came across concept of social inclusion of patient via social skills training in patient with Schizophrenia.
As we know that human is social animal and social interactions are crucial for regulating a successful functioning in the society. According to Mental Health Coordinating Council, MHCC (2007) .Social inclusion is about ability to engage in all aspects of a society that genuinely includes people living with mental illness that supports, intervenes without stigmatization. Further Ware, N.C et.al. (2008) Define it a process through which individuals with psychiatric disabilities develop an increasingly exercise capacities for interpersonal connectedness and citizenship. Social inclusion is essential in schizophrenia as due to cognitive deficits individual social and vocational abilities and hinders routine functionality of a person and make person uncomfortable in social situation. (Dickinson, D.et al.2007).
To promote social inclusion in patient I choose social skills training (SST) as it is utilized as a tool to engage patient in routine life and feel as a part of society. SST consists of learning activities utilizing behavioral techniques that enable persons with schizophrenia and other disabling mental disorders to acquire interpersonal and independent living skills for improved functioning in their communities. (Kopelowicz, A. et al, 2006). Reason for selecting it for my patient is that her cognitive deficits have lead to social isolation that makes her uncomfortable in social situations. I have observed her uncomfort while talking with others, hesitating in marinating eye contact and also unable to share her emotions so SST will sever as a basic step in promoting socialization and also help her to feel confident.
In Pakistan vast numbers of people are suffering from mild to moderate psychiatric illnesses and an estimated number of mentally disturbed people in Pakistan are even higher (Punjab Institute of Mental Health, PIMH 2009). Only few researches have been conducted on this issue due to low research priority, negative perception about mental illness and low priority of mental health training in the country. One of the study done on psychologists experience of cognitive behavior therapy in Pakistan suggests that despite significant number of psychologists in Pakistan yet psychological interventions play only a minor role in treatment plans in Pakistan. In addition psychotherapies need adjustments for use in Pakistan; they shared four major issues that are hurdles in therapy, its related issues, involvement of the family and modification in therapy service and resource issues. (Naeem et al.2010).However Department of Health Promotion Punjab(2009) is primarily concern to initiate appropriate mental health promotion strategies. They have developed manual to be used for the capacity building of health care providers thus bridging a gap between health care delivery system. They have integrated provision of supportive environment and development of personal skills in component of mental health promotion. They have also planned to facilitate social settings which enhance social network for mentally ill patients. Furthermore their approach towards mental health promotion represents social inclusion, participation, strengthening individuals, communities & society to increase social support for sufferers. One of their goals is to encourage people with mental disorders to participate in normal life with their families and friends once treated and stable ,they also provide specialized training to doctors in the field of psychiatry especially for counseling and rehabilitation techniques as this is a weak element in our context .(PIMH 2009).Fortunately it seems that Pakistan has initiated a step towards mental health promotion which is an achievement and it’s our responsibility to take this step ahead toward accomplishing goals.
Social inclusion is necessary for mental health promotion and for the recovery from mental illness. A social connection is the key for including person in society which includes engaging person with its environment. In relation to my patient as she is an elderly woman, along with her disease process there are other factors that have contributed to social isolation for example: her early widowhood, separation from son due to her psychiatric illness, suspiciousness towards her family members all has lost her social role in her family. (CITRA 2007).Many studies have concluded that social inclusion in older people serve as a protective factor to overcome social isolation. These factors are defined as connection with friends, family members; neighbors’ children and community (Warburton.J, Lui.C.W.2007). Research done on preventing social isolation among older people suggests that and social activity and group interventions can alleviate social isolation among older people. Researchers agree that a meaningful social network is a strong support against social isolation in later life. (Cattan.M, et al,2005).For my patient family support is difficult to establish as her son is abroad and she is suspicious to others due to her disease process, presently her community participation can be enhanced for her social inclusion.
Here comes the role of SST, In my patient learning social skills will help her to achieve her own personal goals and enhance her communication of feelings and needs and improve the quality her relationships with others which she think is not good. An effective SST program is based on certain principles that include guidance, demonstration, practice and feedback. The amount of time needed to complete a SST program depends on patients’ performance (Stuart,G.W. 2009).Recent advance in SST by A. Kopelowicz et al. (2006) highlighted that in over 2000 patients with schizophrenia, there was a considerable association between characteristic that reflected social competence, good psychosocial functioning and having confidants as well as subjective reports of high levels of life satisfaction. Moreover research by Dickinson, D.et al. (2007) supports that competent use of social skills by people with schizophrenia is extensively related to actual role functioning in the community. In fact patients with good social skills, as measured by the MASC (Maryland Assessment of Social Competence.), were more likely than others to have been competitively in employment. Which means that patients can prove themselves if they are well treated on time. According to A. Kopelowicz et al.(2006) The components of the SST procedure are derived from basic principles of human learning, I incorporated social learning theory(Bandura,1989) in relation to my patient scenario, as according to social learning theorist “internal cognitive processes influence behavior ,as well as observation of the behaviors of others and the environment in which behavior occur” Similarly it outlines three requirements for people to learn behavior include retention, reproduction and motivation to adopt the behavior. All these interactions help person to modify their behavior. (Smith, E. E, et al,2003).Considering my patient, this learning model will help her in learning and modifying her behavior in front of others and make her feel comfortable and confident to react in a particular situation. Ultimately this will boost her interaction with others comfortably and her antisocial behavior will be changed.
Strategies to promote social inclusion via SST are multidimensional. It varies from individual to group, community and institutional level. At individual level interventions focuses pertinent needs of an individual, successful individual interventions progress to group therapy. At community level, psychological needs of the person should be recognized in adopting social skills by engaging family and creating supportive environment for patient in surroundings. According to A. Kopelowicz et al. (2006) the community-based interactions help them adjust their behaviors to their unique environments and practice and implement the skills that they have tailored. At government or institutional level, awareness session should be held for the provision of knowledge to people and should train personnel, to implement SST as a health promoting practice, for psychiatric patient to promote social inclusion and participation by them, in this way mental illness will not be stigmatized and together we can help theses patient. (MHCC 2007).
I have incorporated Learning-Based Procedures Used in Social Skills Training (A. Kopelowicz et al.2006) within the nursing process which involve interventions from all levels. It focuses on needs identification, which was done thorough assessing patient by taking history, doing mental status examination followed by building trust relationship. Specific to socialization I asked patient to share her expectation from self and what changes would she like to make in her routine life? In which she highlighted that “I want to be accepted by people”. Then setting goals with specification of the social behavior was done by involving patient where patient would be able to participate in social gatherings on her willingness. It was accomplished to certain extend due to her short attention span.
Planning was followed by interventions that includes helping her in promoting relationships wherever she can, taught her to begin and maintain conversation; by motivating her in initiating , help her to have voluntary interactions with others especially with her roommate and neighboring people by involving her in activity with others and take part in group. For this behavioral rehearsal approach was taken in which patient demonstrated skills that are needed for quality social interaction. In addition ongoing corrective feedback was given to modify the behavior like she was encouraged to sit throughout the session with other patients. Social modeling was done by observing behavior during OT activities and accordingly modified with the patient. Additionally positive reinforcement was given on improved social behaviors.
Implementation process was integrated with social learning theory by considering patient ability to retain and focus on her attention span. I intervene gradually by monitoring patient ability to grab things, and by reinforcing positive behavior of patient. Reproducibility was assured and motivation was given on and off. Moreover, I first time saw patient laughing and involved with others during OT activity and her expression of ‘I am enjoying this activity’ made me glad. Evaluation was based on asking question regarding her feelings of modified behaviors, Observed her ease in OT activities, able to express herself and less hesitated and maintain eye contact while talking.(A. Kopelowicz et al.2006)
I always had a negative feeling towards mentally ill patient, while working with my patient I felt blessed because I was able to see her suffering. It was my prejudice that every person is capable to interact with others in the world with social skills and able to communicate in society .I had this understanding that mentally ill patient usually like to be socially isolated because they have their own world and will not be able to adjust themselves but now I understand that there are so many reasons to it. In fact before reading about SST I didn’t know that it has profound benefit in promotion of mental health. This writing helped me to correct my attitude towards mental illness and enrich me with knowledge and importance of social inclusion in patient’s life.
To summarize socialization is a lifetime process and it has great value in every aspects of life. Promoting social inclusion by helping patient to learn social skills will offer support, built confidence , enhance self-esteem in patients which eventually improve the quality of life, promote recovery and leads to successful functioning of individuals in society. As concluded by MHCC (2007) “the social inclusion approach offers a valuable frame work to view both the individual and collective responsibility for good mental health”.
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