How to give psychological support to spinal injury person?

Psychologists affirm that there are patient attitudes that are considered normal and are modified after overcoming a series of stages such as: shock, denial and confrontation. With the help of loved ones and medical-health care, over time they must overcome it, reaching the stage of acceptance and adaptation, and can then learn to live with the disease.

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Episodes of sadness and depression can appear continuously, but it cannot be generalized that all patients go through all the stages, since each individual reacts differently depending mainly on their personality, beliefs, values, experiences and the affectation that you have in the field of education and/or work, social, family, economic, etc.

The role of the healthcare team is important from a medical and human perspective. It is necessary to take into account the type of patient, provide personalized and individual treatment, inform and communicate appropriately.

It is interesting to provide recommendations that help manage the disease process: live in the present, measure life in terms of quality and not quantity, look for solutions, take care of yourself, distract yourself, trust the medical-health team, prevent illness is the center of their life and rely on related organizations and associations to provide specialized care.

KEYWORDS

Psychosocial aspects, spinal cord injury, rehabilitation, adaptation, quality of life, family.

INTRODUCTION

Most people are born with skills that are needed or acquired over time. Thanks to a series of impulses, movements are made that allow us to carry out different types of activities on a daily basis (climbing stairs, opening a door). On many occasions we are not aware of the value and importance that we give to the tasks that we usually do, since for a healthy person, without any impediment, it does not require effort. However, there are people such as those with spinal cord injuries who cannot perform or have difficulty performing these basic activities.

In industrialized countries, spinal cord injury is a public health problem of the first order, since it causes permanent disability, with significant personal, family and social repercussions 1 .

Faced with this disability, either from birth or suddenly due to trauma or over time due to a degenerative disease, people have different ways of reacting and adapting. In which much influences the personality of the individual who suffers from it and the environment that surrounds him. Very important psychological and adaptive changes are generated in all aspects of life, especially physical, psychosocial and emotional alterations. Psychosocial changes vary and evolve over time, going through perfectly established psychological stages 2 .

It completely changes their way of life, their future projects, their work, etc. it hinders goals, dreams and illusions. This makes you feel that life as you knew it will no longer be the same, so that feelings of sadness and inferiority take over the individual.

The first reactions that they usually manifest are, in general, anxiety, anguish and fear. These are the psychological reactions that are implicit in any serious pathology that implies consequences, coming to see suicide as the only solution to their core problem.

In one way or another, the affected person needs the almost constant help of other people when carrying out any daily activity (especially people with quadriplegia) such as washing, dressing, cooking, among many others. The physical and psychological company that they have can make the individual feel like a baby, who is unable to do anything alone. So he almost totally loses intimacy and independence from him. Faced with this situation, many go through a stage of isolation in which they refuse to leave their home out of shame at feeling inferior to the rest and for fear of being rejected by society.

Due to the organic or physical sequelae, from the psychosocial point of view, an alteration of body image is generated that affects self-esteem and self-image. Adapting to the new situation provokes diverse emotions and feelings such as anger, fear, anguish, impotence, sadness, as a consequence of the decrease in the expectations of their life project, which has been cut short 3 . So sooner or later psychological illnesses can develop with different intensity. The most characteristic example of these diseases is depression; and its intensity will vary from sadness to the most serious states, which include suicidal thoughts or attempts.

To prevent the individual from reaching such an extreme, in which he wishes to die, specialists, doctors and assistants are in charge of rehabilitation with the aim that he can recover, even a percentage of the mobility he had before materializing. the illness.

This situation is aggravated in countries where they lack adapted infrastructure or social assistance.

Fortunately, Spain is a developed country with a system aimed at avoiding the exclusion of the disabled from society. Through social programs and economic aid, it is intended that the physically handicapped can overcome barriers. Even with everything, all the measures are few to achieve their full recovery and inclusion.

The affected person sees altered psychosocial factors in various areas: family, work, economic, architectural barriers, social prejudices, etc.

On a personal level, he has fears of the type of not knowing what he is going to do with his life, losing the person he loves, not being loved, losing the approval of others, losing or having difficulty having, maintaining or finding a job, self-esteem, feelings of not being worth anything, of not being able to carry out any of the activities that they used to carry out, feeling undervalued before themselves and those around them. At this level, it is not possible to generalize since each individual reacts differently depending on his personality and his idea of ​​his self-image.

Within the personality, sexuality is an important part, not only because of the fact of achieving the desire for contact, of intimacy, of achieving pleasure, tenderness and love, but also of the individual’s need to fully realize himself from his condition of being sexualized . Its full development, in all dimensions of life, is essential for individual, interpersonal and social well-being. In most people with disabilities it is affected for multiple reasons, so a rehabilitation program that does not include education, guidance and treatment of sexual needs cannot be considered complete.

At the family level, the family itself suffers and results in insecurity. Their emotional commitment is related to the severity of the injury, although it is not always proportional. The family emotional response and even the personal one, will depend on a series of multifactorial circumstances such as intelligence, psychological defense mechanisms, expectations and previous experiences.

Families will adopt classic patterns, either rejection of the subject and his or her illness, for compromising the family balance, or flexibility, with a clearly open and flexible attitude, adapting to the problem as quickly as possible, passing through resigned acceptance of the facts. In both situations, the despair in the first days is even greater than the affected person, showing excessive worry or inhibition, even fleeing from the hospital to avoid anguish 3 .

Another important factor is the prejudice of individuals and historical and cultural aspects. It is a social phenomenon with personal manifestations. The way this person “sees” is modified according to the social, moral, physiological, ethical and religious values ​​of the different cultures and historical moments.

It is evident that, although the psychosocial repercussions will largely depend on the importance of the injury or disability, psychiatric and psychological care is needed from the moment of diagnosis that facilitates the acceptance of the limitations on the patient and the family, in an attempt to achieve the most complete rehabilitation possible, which allows socio-labor and family reintegration. And so, psychotherapeutic care is imposed on children and spouse to reduce the time of evolution and the medical and psychosocial sequelae 4 .

BASIC CONCEPTS: WHAT IS A SPINAL INJURY? 3

The spinal cord is the pathway that messages use to travel between the brain and different parts of the body.

Spinal cord injury is damage to the spinal cord, which leads, depending on its severity, to the loss of some functions, movements and/or sensitivity. Normally these losses occur below the level of the injury. Spinal cord injuries are divided into two types:

• A complete spinal cord injury: when there is no function below the level of the injury and there is no sensation or voluntary movement. Both sides of the body are affected equally.

• An incomplete spinal cord injury: when some function prevails below the primary level of injury. A person with this type of injury may be able to move one limb more than the other; you may feel parts of your body that you cannot move, or you may have more functions on one side of your body than the other.

In turn, according to the American Spinal Cord Injury Association (ASIA), another classification can be made taking into account the neurological level (last healthy sensory and motor level, below this level there are alterations, even if they are minimal):

• Complete Spinal Cord Injury A : There is no sensory or motor preservation below the level of injury and sacral segments are covered, that is, there is no sensitivity or control to pass or defecate.
• Incomplete Spinal Cord Injury B : There is preservation of sensitivity but not motor below the neurological level encompassing sacral segments, that is, there is sensitivity to defecate and urinate, but no voluntary control.
• Incomplete Spinal Cord Injury C : There is preservation of sensation and strength below the level of injury but the muscles are weak and considered non-functional.
• Incomplete Spinal Cord Injury D : The muscles below the neurological level are functional, 75% of them.
• Incomplete Spinal Cord Injury E: Strength and sensitivity are practically normal.

PSYCHOLOGICAL STAGES 5

Once the spinal cord injury is suffered, they experience a series of common psychological stages, although it should not be generalized since, as mentioned above, it must be taken into account that each patient is a unique case by itself.

The different stages it goes through are 1,3,6 ,:

1. Psychological shock stage: After the accident, there is a period of time in which the individual is not aware of what is happening around him, which causes confusion. The patient shows special interest in the loss of mobility and sensitivity of the affected areas in his body, and increases the fear that the pain will continue. The fear and fear will also increase at first, caused by the lack of information about what is happening to him.

This state will produce anxiety, which can cause shock (disconnection) that can cause space-time disorientation, further aggravating their mental integrity.

A remarkable aspect is the lack of interest shown by those affected, focusing their attention mainly on their organic state, accompanied by a great affective lack that is covered by the closest relatives.

2. Denial stage: Denial is understood as a defense of reality “this is not happening to me”, a general human reaction to any unpleasant news or event.

This reaction is partly positive since it gives the individual time to realize what is really happening to him. This reduces the risk of personality problems. Denial results in a complete or partial distortion of reality.

The duration of this stage should not be very long since the individual’s personality and perception of reality could be altered, which will make the rehabilitation task much more difficult.

3. Protest stage: This stage is characterized by the partial capture of reality, the patient’s little tolerance and a feeling of injustice that clouds his mind. So he does not collaborate with the treatment and leaves his cure in the hands of the doctors. There is criticism of medicine, doctors, hospital staff, etc.

The affected person goes from the stage “this is not happening to me” to the stage of “why is it happening to me”. The physical limitation he considers as an injustice, which limits his vision of the future. During this stage he may develop an angry situation, expressing his aggressiveness against his family, friends and medical personnel. This is a danger since he can drastically break his relationships, both friendship and conjugal, at the moment when he most needs their help. This is the stage in which the patient suffers the most social problems.

Therefore, great understanding and sensitivity is necessary at this stage, in which family, friends and support staff must understand the person’s situation and never leave it aside.

The main problem is that the anger he suffers does not disappear, and he is classified as a dangerous, hostile and uncooperative patient, which could influence the quality of care and the inability of doctors to recognize a subsequent favorable evolution in his character, behavior and cooperation with rehabilitation.

4. Adaptive stage: Once the protest stage has passed, the patient’s attitude on the subject of his recovery changes completely, he tries to achieve an adaptation generally manifested by an excess of interest in physical rehabilitation.

During the rehabilitation period, you can undergo three possible evolutions depending on the degree of physical and psychological recovery and the time dedicated to the recovery task:

• Return to the stage of protest or hostility.
• I go to the depressive stage.
• Go directly to the adaptive stage, without having to go through the depressive stage. Which would mean a success of the attempt.

5. Depressive stage: Live life within a pessimistic filter, without seeing a positive way out of your problem. Therefore, he requires a great emotional and psychological support that will be given by the staff that attends him, his family and friends. At a certain point in the rehabilitation process, the presence of said depression should be expected, whose symptoms could be some of these:

• loss of appetite
• Night terrors, insomnia.
• Loss of interest in leisure or pleasure activities (sex).
• Undervaluation.
• Guilty feeling.
• Decreased ability to concentrate and difficulty in solving certain problems.
• Inconsistency and indecision.
• Continuous thoughts related to death and suicide.

Depressive feelings can be expressed in different degrees of intensity, but these are not always expressed verbally, but can also be manifested through psychosomatic organic symptoms.

At this stage, they should be allowed to express their feelings to facilitate the rehabilitation process.

6. Identification/adaptation or final stage: Assume the physical limitation you suffer from and change your way of seeing reality from a more positive perspective. Likewise, he will focus on developing his own potentialities, and most importantly, never look back as he could fall back on one of the previous stages. “ The important thing is not what is left but what we do with what we have left” .

These phases that the patient goes through constitute a process, from which the desired result is not always obtained since, for different reasons, they may remain stuck in one of them or relapse into a stage that has already been overcome.

It is also necessary to point out the evolutionary parallelism that exists in the relatives, who also live the phases that their relative has gone through. But they do not usually occur at the same time, due to the speed of the process in the family, or because of the knowledge of the injury and the prognosis of its evolution.

Knowledge of the stages through which he goes through is very important for people who work with this type of patient, in order to facilitate understanding and relationship with him.

SITUATION AT HOSPITAL DISCHARGE 3,7,9

An aspect that takes on great importance in the life of the patient is hospital discharge after admission, which gives the individual a new personal condition, turning his previous life completely around, since he will have to focus from other perspectives on the activities he carried out in the hospital. work, social and family environment.

Every person has the right to education, training, culture, work and leisure, regardless of their disability, as well as to ensure that their integration into society is as complete as possible, allowing them to play a constructive role in it.

The main problems that a person with spinal cord injury encounters are:

• Lack of information on the part of society, of what it can and cannot do.
• The accessibility barriers that influence their integration at all levels.
• Problems accessing education.- Incorporation into work is difficult.
• Your purchasing power decreases as your expenses increase and your income decreases.

Housing: The first problem that the injured person encounters is that his home is full of obstacles: stairs, doors that are too small, tables that are too low, cupboards that are too high… also, barriers outside or in the access to the home, such as the construction of ramps and elevators, are more difficult to solve, since public and/or private organizations are involved in their realization.

Transport: Another important problem is that of displacement, since it is not easy to use public means of transport because they are still poorly adapted. They need to have a platform to replace the stairs and they also need to have more free space to accommodate the wheelchair.

Nowadays, there are already exclusive buses for the disabled and some urban buses have adaptations for them.

As for other means of transport such as the metro, stations have been adapted in certain cities: the accesses to the metro have a ramp, there is an elevator to get to the platform…

Widely adapted is the airplane. The airports have specialized personnel who are dedicated to your transfer to the plane, entering first.

The ship, however, is not yet adapted, except for a few luxury ocean liners.

The train has special wagons with large areas for wheelchairs, with the inconvenience that the companion cannot go next to him because there are no seats for them.

Education: Access to it is difficult, mainly due to the fact that, in most cases, they are forced to change to a college or university adapted for the disabled. If we take into account the competition that exists to access a job, higher education is essential to be able to compete with the rest, with the inconvenience that the disabled person has more problems when accessing them.

Work: Work and economic independence are essential for people to have a feeling of personal sufficiency, dignity, self-esteem and to feel oneself as a valuable member of both the family and society. Finding a job in this situation becomes complex, since companies consider that sitting in a wheelchair is synonymous with disability, not giving the spinal cord injured person even the opportunity to prove his worth, although it is true, little by little progress is being made in its integration.

The main obstacles to labor integration can be divided into 4 blocks:

• Personal: physical conditions and problems to continue their training.
• Social: relative to the opinion that society has.
• Legal: regulatory insufficiency and non-compliance with the existing one (private companies are required to have 2% disabled people in their workforce and 3% in public companies).
• Structural: shortage of jobs in companies.

Sport: Understood as a means of expressing personality, it is one of the most important channels of communication, liberating energy, a means of participation, creation, learning, individualization and socialization 8 .

The person with spinal cord injury has a lower degree of mobility depending on the type of sequelae that may occur, atrophy, a decrease in their ability to move, to a mild, moderate or severe degree, in the corporal, postural and functional, in their basic motor ability, and/or their ability to express themselves.

Sport is vital for the development and maintenance of biopsychosocial functions and capacities; and through this we can contribute to the development of the remaining movement capacities of people with physical disabilities.

Family: There are some external difficulties that affect such as excessive family protectionism, with acceptance and promotion of inactivity. This paternalism limits the individual even more than the disease itself and the deficiencies that derive from it, making him a passive and marginalized subject, who has to face physical and psychological barriers that are more difficult to eliminate.

People who were previously single will have more difficulty finding a partner. The increase in divorces or broken courtships due to spinal cord injury must be taken into account, due to the implications this has on the patient’s state of mind and subsequent affective development.

When talking about paternity, in many cases, in men artificial insemination would be necessary and, in the case of women, the chances of pregnancy would be the same since the menstrual cycle is not altered, however they are pregnancies of risk with possible complications both in pregnancy and childbirth.

CONTRIBUTIONS THAT IT MAKES AND USEFULNESS

This work analyzes the problem of spinal cord injuries from the psychological point of view not only of the patient but also of those around him, especially the family and also from the social point of view (work and social relations).

In it, special mention is made of the abrupt and brutal change of life and social role experienced by a person, usually young, who sees their life expectations truncated.

Analyzes the complex psychological phases that continue in their evolution, the majority of these patients as well as the complex relationships with the environment, including relationships with a partner.

Awareness of the delicate psychic balance of a problem that is more and more frequent in industrialized society and that needs attention and help, not only specialized in institutions created for this purpose, but closer, from day to day. In addition to medical knowledge, a good dose of psychology must be included.

It is useful for all health levels, both for medical personnel, psychologists, physiotherapists, psychiatrists, nurses, assistants, caretakers, as well as for related associations, as well as for anyone with an interest in the matter.