Occupational therapy of the mentally ill

Hellerstein indicates the following important signs of occupational therapy, affecting the restoration of activity of patients:

1. Compliance with human needs
2. Target activity
3. Powerful Exercise Impact
4. Mobilization of activity, attention , etc.
5. The need for effort, tension
6. Extensive compensation options
7. Overcoming difficulties and obstacles, the possibility of regulating their dosage
8. Incorporation into a vital rhythm
9. Efficiency, prerequisites for organizing feedback
10. Favorable field for distraction, switching, change of installation
11. The birth of positive emotions - feelings of satisfaction, usefulness, etc.
12. The collective nature of labor.

Contraindications to occupational therapy

• Occupational therapy is absolutely contraindicated in acute painful conditions , pathology of consciousness , catatonia , etc.
• It is temporarily contraindicated with active drug treatment , severe depressive and asthenic conditions , if the patient has negativity to work.

During occupational therapy, one must be guided by the types of labor available to the patient and his zone of proximal development (according to L. S. Vygotsky ). For this, a special modification of the profession is used (Gellerstein).

Principles of using occupational therapy:

1. The work of patients should be effective, and the patient should see the results of their activities.
2. Individual accounting of the development of patients is required.

• Hallucinatory syndrome . Active inclusion of patients in labor leads to the weakening of hallucinations . But labor must be intense, active and not amenable to automation . The mechanism of the therapeutic action of labor in these cases: the suppression of the pathological dominant and the creation of a new labor dominant. Patients suffer not so much from the hallucinations themselves as from the preoccupation of the psyche with these experiences; active labor reduces such absorption, filling the patient’s mental life with new healthy content.
• Depressive conditions . It is important for patients to distract from painful experiences, give hope for recovery, create a dominant to distract from anxious thoughts. Labor should be exclusively individual, allowing to evaluate productivity and alternate different forms of work. This work should be based on familiar skills , it is important to show the patient its usefulness, suitability for meaningful, useful activities.
• Motor inhibition . A work partner can only be a patient who is slightly superior in activity, or a work instructor. The method of working tests: for some time the instructor works with the patient in paired work, identifies the patient’s rhythm, tempo of movements, style of his work, characteristic shortcomings, etc.
• Mental retardation . If these patients have an interest in labor, then they are no different from healthy ones (according to experimental data). The mentally retarded (for example, with Down's disease ) have well-developed motor memory and diligence (they are very diligent); in addition, they are very emotional and empathic .

Employment therapy began to spread in the Soviet Union since the 1930s . Although the system of social and labor rehabilitation in the USSR was considered an unconditional achievement of Soviet psychiatry, it was characterized by a number of shortcomings. The work, as a rule, was low paid and unattractive for patients; the proposed choice of types of labor was reduced mainly to routine and primitive. There was almost no possibility of a phased labor rehabilitation, labor retraining and reorientation were difficult due to the limited types of specialties, the lack of differentiation depending on the individual needs and inclinations of patients ^[1] .

The recollections of a former patient of the Sychev Special Psychiatric Hospital, dissident M. Kukobaki, have survived : “The so-called“ occupational therapy ”has turned into a profitable commercial enterprise for the authorities. The machines are arranged without taking into account sanitary standards, cramped. All ventilation is a few window leaves. Patients under direct or indirect pressure are forced to work from morning to evening. In the summer months, work is also practiced after dinner. Of course, all this is formally voluntary. But try not to go! They will immediately find you have a “change of state” and torture will begin with various injections, persecution by orderlies - criminals , etc. ” ^{[2] [3]} . V.P. Rafalsky, who spent twenty years in special type of psychiatric hospitals, also had similar impressions: “There was a factory for five hundred cars in a psychiatric hospital. The working day is six hours, thanks to God, for the roar is at the factory - the walls are shaking, and, in addition, they add a lot of speakers, and to their fullest, the tape recording of modern supermusic. <...> Drove to work from the first days. Can you imagine what it means to work under antipsychotics ? And they worked ” ^[4] .

Occupational therapy in some Soviet special psychiatric hospitals was mandatory, in some it was only encouraged by the administration. Patients worked in cartoning, weaving , bookbinding , sewing and other workshops , receiving extremely low wages for this - from 2 to 10 rubles per month, transferred to a personal cash account. The administration of special psychiatric hospitals this work was very profitable, since the sales price of manufactured products was ten times higher than the cost of labor ^[3] .

In post-Soviet times, most of the labor workshops that existed in practically all the psychiatric hospitals of the USSR turned out to be abandoned due to lack of funding; the volume of occupational therapy decreased, the remuneration of patients is purely symbolic, human rights violations continue to be observed ^{[5] [6] [7]} . Often in hospitals there is an exploitation of the labor of patients, sometimes involuntary: patients clean the territories and departments, participate in repair, unloading and loading operations, etc. ^[7] Meanwhile, according to the Law of the Russian Federation “On Psychiatric Care and Guarantees of the Rights of Citizens under its provision ” , patients of an institution providing in- patient psychiatric care have the right to“ receive, along with other citizens, remuneration for labor in accordance with its quantity and quality if the patient is involved in productive work ” ^[8] . According to the UN document “Principles for the protection of mentally ill persons and the improvement of psychiatric care”, “under no circumstances should a patient be subjected to forced labor. <...> The labor of a patient held in a psychiatric institution should not be exploited. Any such patient has the right to receive the same remuneration for the work performed by him that, in accordance with domestic law or customs, a person who is not a patient would have received for similar work ” ^[9] . Cases of gross exploitation of the labor of residents were also noted in neuropsychiatric boarding schools ^[10] .

In a survey conducted in the 1990s, it was noted that Russian patients expressed dissatisfaction with the poor organization of occupational therapy in all organizational forms where it was used. Patients stated that the types of work they were offering were primitive and monotonous, did not correspond to their needs and labor skills, occupational therapy was essentially compulsory. Surveys showed that occupational therapy in the form in which it exists in most of the studied psychiatric institutions, not only does not achieve its goal, but is also one of the main sources of patient dissatisfaction ^[11] .

With the deinstitutionalization of psychiatry , a number of Western countries rejected occupational therapy and switched to work under an employment contract, which guarantees the patient's rights and payment for his work in full ^[12] .

• Social rehabilitation
• Biopsychotherapy

• Gellerstein S.G., Tsfasman I.L. Principles and methods of labor therapy for the mentally ill. - M., 1964 .
• Gellerstein S.G. To the construction of the psychological theory of labor therapy // Restorative therapy and social and labor re-adaptation of patients with neuropsychiatric diseases: Proceedings of Vses. scientific conference November 10–13. 1965 - L., 1965 .
• Noskova O.G. The psychology of labor. - M., 2004 (chapter 10 “Psychological aspects of the social and labor adaptation of patients and disabled people”).