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In the review Trends in Rehabilitation Policy," the Audit Commission and the King’ s Fund suggest that the importance of rehabilitation is increasingly being recognized. More medical specialties include it as part of their service and it covers a wider range of aspects than simply physical functioning. In the health and social care sectors (at both a local and national level), rehabilitation is seen as a means of easing discharge from hospital, reducing inappropriate long-term placements in institutional care, improving the quality of service users lives, and offering a more cost effective use of resources. However, there is a lack of clarity in the situation, insofar as there would appear to be substantial gaps at ground level between the theory of rehabilitation, its practical application and its effectiveness as an end in itself. In the absence of addressing the longer-term emotional, psycho-social issues arising from residual disability as a consequence of stroke in a life situation, and the long-term integrated maintenance in the community, patients and their families, in the aftermath of rehabilitation, often gradually regress to a significantly lower level of functioning, which can precipitate further crisis : leading to loss of physical ability in the patient, anxiety, distress and possible burnout in the carer and even to the breakdown of family and marital relationships," yet there is still no structured provision of counseling within statutory services for individuals and their families to help them adjust to their changed circumstances.
It would appear, then, that a traditional medical approach to rehabilitation represents a linear process, from the acute stage through to discharge. However, the authors’ experience and research indicates that this does not accurately illustrate the pattern of recovery from stroke. This is supported by disabled people too, who are calling for better rehabilitation facilities in order to help them lead more independent lives."
What is rehabilitation ?
During the acute phase of the stroke, people want to put their faith in experienced and trusted experts who will help them make sense of the event, take all the actions necessary to ensure survival, and provide comfort and human warmth during the crisis. However, as the acute stage passes, the increasing recognition by the patient of the physical limitations caused by the stroke may be accompanied by an expectation of a fairly quick and full recovery. Patient’ s views of recovery are based on their past experiences of physical illness or injury. These are usually `passive ’ in nature, and the notion of `cure’ is invested in the doctors, nurses and therapists. As would be expected with such a negative life event, acute psychological reactions are often observed, including grief, anxiety, anger and depression. However, these responses often appear to be categorized as `mood disorder ’ and referred to psychiatrists or psychologists contained within mental health and the medical model. While only concentrating on the malfunctioning of the body and it’ s parts due to stroke, and only intervening either physically or chemically this approach often loses sight of the person as a human being. In doing so, it may ignore the complex interplay among physical, psychological, social and environmental aspects of the human condition the person and his} her family has to cope with in a life situation in the aftermath of stroke rehabilitation.
Like all chronic illness, stroke represents an assault upon many areas of everyday life, encompassing home, work, leisure and social relationships including relationships with self and others. It may shatter personal images, family life and future ambitions. Therefore, patients and/or carers are likely to have unrealistic expectations of a full recovery from the stroke event, or be in danger of falling into despair. However, when there is poor or no acceptance of the event and [it’ s] possible consequences, added to an inert expectation that they will be `made better’ , these people are often discharged from rehabilitation settings still searching for the `cure ’: life as it was before the stroke unable to incorporate `their’ stroke disability into `their’ future lives.
The primary features of this impasse, in the long-term are : the retention of the pre-stroke persona and lifestyle expectations; disappointment with recovery and an inability to move out of the `sick-role ’ , resulting with feelings of being abandoned by the professionals, the NHS and the system as a whole ; a lack of acceptance of a `new or different me’ and an inability to develop a new lifestyle and interests; post-stroke depression; guilt a belief that the stroke is a punishment for some kind of actual or imagined wrong doing in the past; and a significant degree of dependency whilst waiting for thing’s to get better. Which adds to an already significant burden on the carer(s), families and} or resources in a community.
The reality of working with this patient group is that the current pattern of fragmented rehabilitation takes place across a range of professional groups and agencies. Each has its own model and perspective for practice, but there is no meta-structure to guide the process as a whole. It needs to be said, a patient’ s experience of stroke and rehabilitation is not fragmented but is a fully encompassing life event. There is clearly a need for a model of integrated rehabilitation which can be adapted by each professional involved, yet which provides a coherent overview of the process of recovery from the
Is there an alternative ?
From this perspective then, rehabilitation is defined as a process of adjustment to change such that order and meaning can be re-discovered in a life situation. The focus of rehabilitation counselling is to facilitate the patients moving through periods of emotional adjustment and grieving during the physical rehabilitation phase. It is proposed that being sensitive to the patients agenda and honouring his or her experience is a fundamental premise of the rehabilitation process.
Facilitation of the patients and carers emotional adjustment through counselling may enhance other aspects of the rehabilitation programme and outcome. However, in using this approach, there would need to be closely integrated multidisciplinary working across professional boundaries, with a continuous and active dialogue. Rehabilitation would certainly need to be client centred not service centred, and be dictated primarily by a model of re-education and psycho-social adjustment within the context of good quality medical care and physical rehabilitation. So, the two could work very nicely hand in hand. Rehabilitation counseling would provide the long neglected aspect of emotional rehabilitation to complement the emphasis on physical rehabilitation of stroke.
Thorne emphasizes the points well in her seminal work on the experiences of people living with chronic illness: Chronic illness is much larger than simply curing ¼ it has to do with the very essence of human aspirations and meanings. People do not become less human, less interesting or less deserving because they have un-resolvable disabling conditions. Rather they continue to learn to adapt and to live their lives as well as they can manage. In other words, they seek a state of health that represents their best effort within the specific challenges of their condition. And helping people to achieve this health is, after all, what the healthcare system is supposed to be about.
Recovery from stroke
Firstly, unless there is clear information available about the likely results of counselling intervention from short-term rehabilitation through long-term adaptation, people who have suffered a stroke will not receive optimum treatment. Second, rehabilitation practice based solely on clinical, physical functional outcome is no longer acceptable, and thirdly, given the current financial situation in the health service, and the number of people with stroke, there is a reluctance to purchase services without clear evidence of it’ s efficacy. The practice of medicine has always depended on doctor’ s and nurse’ s. The therapy professions have grown up to supply new kinds of skills. Certainly, the medical commitment to stroke rehabilitation is more positive now, and the specialized skills of occupational therapy and physiotherapy can hardly be in doubt, but it has to be recognized that there is a need for far more than physical therapy. The person with a stroke may have many requirements and, therefore, may need other specialized interventions to meet those needs. To that end, an evaluative research initiative is at present ongoing and will be reported at a later date.
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