TOWARDS A REHABILITATION WHICH TAKE INTO ACCOUNT THE PATIENT AS A HUMAN BEING. BUT WHICH KIND OF PERSON?

Beside the specific duties, the activities carried out in the health field have the natural purposes to give a service to meet the real needs of people with disabilities. Particularly, the rehabilitation proposes to assure the re-affirmation of the personal "IDENTITY" through an active process, aimed at reducing the effects of the impairment in daily living. Speaking of an aphasic patient who maintains the role of "a person who communicates", in spite of his great problems, the question is difficult because it contemplates the elimination of any misunderstanding about the nature of "that" identity. In this sense the "therapy of aphasia" will not any longer contemplates only the medical skills, as the problem itself involves - since the beginning - emotional, behavioural and social aspects. The patients require the assistance of different operators working altogether to improve the quality of patient's life. According to this view, the rehabilitating process will be necessarily centred on the disabled person and will require the active assistance of operators, family members and caregivers. In fact , sharing the knowledge about the "aphasia" problem and discussing the different point of view, it will develop "the global intervention", which is on the basis of "holistic approach". But what is this great knowledge to share in order to guarantee an effective intervention taking into the account of the personality of the patient and his needs as a being human ? And who is the person who the treatment is addressed to? Is he considered a "patient" to deserve to be cured ? How much about him are we willing to know? How different is he from what we have read in the copybooks? How much of him is beyond our understanding? What would happen to our "identity" if we were suddenly thrown into a hospital, wearing pyjama in front of people we don't know, unable to communicate. We'd acquire a "standard identity" and we'd become " the aphasic" patients ? Who would decide to relate with us could he exactly say who we are? And we were the day before could it make any difference? It is advisable to analyse a lot of possibilities when we meet a person affected by communication disorders, during his period in hospital, at home in the social environment as well.

DISCUSSION TOPICS

Anyhow, there are many topics which should be discussed by the health/social operators. We'd consider some of them. Aphasic people are not considered "ill" clients or patients of somebody, except in the moment they need to have specific therapies ( hypertension, depression, epilepsy…). It's wrong to mix up the neurological pathology ( ictus, trauma, tumor) which requires the medical therapy with the communication problems which require the help of a team of operators according to their professional skills.

THE SOCIAL EFFECTS AND THE RESPONSABILITIES OF EVERYBODY

We all know that the "aphasic clients" suffer a disability which limits the social activities and, therefore, the social interactions. The partial or total incapacity to speaking or to understanding hinders activities such as reading, listening, writing, as well compromises also the participation to social events in which it is necessary to ask for getting information, to organise activities, to attend conversations, to give psychological support to people, to share opinions, ideas, point of view with other people. On this subject, if it is true that the aphasic client has necessarily to adapt himself to some changes in his life, it is also true that for helping the person to find a balance, the operators will have to modify and develop new strategies of communication suitable to interaction.

THE AUTONOMY OF THE APHASIC CLIENT

The speech impairment of the aphasic clients don't damage at all attention, memory, reasoning and the capability of perception of desires and emotions as well. Though with great variability ( due to differences in the extension, nature, site of the brain damage), many aphasic clients are able to think, remember and plan, in spite the language has lost its quality. However, it is true that in many cases a reduced efficiency of the cognitive skills exists; this is clear, for example, when an aphasic client is having a conversation and he looks immediately tired and unable to remember the topic of conversation, when he is slow in passing from a topic of conversation to another , when he has difficulty in maintaining the thread, in starting and concluding a discourse, in organising his own thoughts in a verbal diagram. It is useful to point out that these cognitive aspects cannot be mistake neither with mental disorders nor with specific alterations of the psychiatric pathologies. The above mentioned pathologies cause the loss of the autonomy of the client in daily living (eating, dressing, walking) and in activities such as going shopping, deciding what to eat, managing money, carrying out a job, driving. This is the reason why the operators must decide together with the family a kind of assistance ( giving drugs, creating a protected place..) Speaking of aphasia, the situation is completely different. In this case, the clients, even if with their limits, are able to manage their health state and the operators will have not to "assist" , but, on the contrary, to encourage any form of self-determination.

THE COMMUNICATION RESOURSES OF APHASIC CLIENT

Notwithstanding, "aphasia", is always, in some way, responsible of alterations in the verbal communication (speaking, writing, reading, understanding the words). The "aphasic clients" have a considerable amount of communicative resources. In fact , when at ease, many clients can communicate using few words, gestures, fragments of phrases, movements of the head, face expressions, particular intonation of the voice and writing expressions.

THERAPY AND RECOVER OF APHASIA.

At the moment drug therapies of reliable efficacy in the treatment of aphasia do not exist. It does not mean that drugs are not helpful in managing the medical correlated problems. But it is necessary to take into consideration that frequently the aphasic client has considerable states of depression, due to the language rehabilitation which has a great importance on the well being of him and therefore, on the quality of his life. We refer to objective factors (inefficacy of the treatment, long terms, availability of cognitive resources) and subjective ones (tasks of increasing difficulty, awareness of his limits, long concentration required). All these factors act unfavourably on the mood of the aphasic client causing a depressed state, which the operator's expert eye catches and values at the right time. In this kind of situation, the specialists will be often asked to start a pharmacological treatment or a behaviour therapy. In the former case the therapist will have to be informed about the use of drugs, how long the treatment will last and, above all on the side effects, if any, which may compromise the rehabilitating process (sleepiness, little concentration, lack of balance, disorder in walking). The speech therapy too notwithstanding its large use, does not guarantee a definitive cure, but develops the use of the remaining capacities of the client, by learning alternative strategies of communication.

WHICH ARE THE APHASIC CLIENT'S NEEDS ?

Notwithstanding the speech impairment prevents from having a life in total autonomy, aphasic clients need, as all people, to organise directly their social life. The aphasic clients are very often unable to identify the different professional figures (doctors, physiotherapists, speech therapists , nurses, social workers). They are not able to ask "Who are you?", What do you want from me?" Therefore, it would be advisable to create suitable conditions to enable the client to ask those questions which usually remain with no answer (Am I mentally disturbed?), to ask information about the cause and nature of "aphasia" (what happened to me?), about the "prognosis", (How long it will be take to be well as before?), about the period in hospital (when I'll be able to go back home) about the expectations of the rehabilitation treatment (will it be possible to speak as before?). A frank share of the knowledge between operators and aphasic clients often allow to avoid the dangerous risk to believe in a miracle. Only the "truth" on the real state of health will prevent the aphasic client from creating useless expectations. The operators will have to encourage a true dialogue to which the aphasic clients will actively participate, with the limits bound to the available resources, and therefore recovering partially that identity already mentioned.

HOW TO COMUNICATE?

We suggest to respect some basic indications for a correct communicative exchange, such as: n Talk directly to the aphasic client, when you have to communicate information regarding him, and only subsequently to other people. n Since the beginning try to explain to the aphasic client what is your professional role. n Act with respect and sensitivity towards the aphasic client. n Encourage any effort of autonomy showed by aphasic client in his everyday life activities, by suggesting practical solutions to the language problems, walking, personal hygiene, feeding, in accordance with every professional figures expert in their field. THE PLACES OF COMMUNICATION THE HOSPITAL The hospital experience does not allow to the aphasic clients any possibility of control on their conditions; doctors and paramedical personnel do their best in order they are daily nourished, helped, supported. Such initiatives make them lose their trust in their capacities and subsequently to need help as "ill client". For these operators, the more useful suggestions in order to encourage the active participation of the aphasic clients, will be: n ability of listening to him n the appreciation of his efforts to reach a language autonomy n to give trust n the development, when necessary, of non verbal communication useful to know the real needs of the person.

FAMILY

If the experience of hospitalisation and being considered as patients result dramatic for who has speech impairment, also the relationship with the members of the family or caregivers is full of problems which are to be shared with the operators. In the family relationship, the loss of the language causes emotional and behavioural alterations, and exchange of role. Members of family not sufficiently informed by the operators leave their job and their interests to transform themselves in full time assistants. In this way they take care of their loved one like a child, removing him from responsibilities and decisions. For these reasons, the operators have to develop a closed relationship with family members in order: · to give information about "aphasia" and the purposes of the rehabilitation · to encourage the communicative strategies developed inside domestic walls · to know aphasic's social and personal aspects which can play an important rule in the communicative skills. THE

REHABILITATION SETTING

Without considering the technical skills of speech therapists, it is necessary to go into the depth of some aspects of the rehabilitating setting. For example, the selection of the purposes of the treatment programme, discussed together with all members of the rehabilitating team, takes place from a careful valuation of the communicative needs in daily living. From time to time, with regard to the specific priority, it will be decided on the disability, considering a series of strategies set in a rehabilitating training. Consequently, the therapist will have to value several factors such as: the motivation, the participation, the awareness, the family context, the personality, the sharing of purposes and expectations, etc. When possible, the therapist will have to fix a relationship with the family or caregiver in order to not create different expectations regarding the ones discussed with the aphasic client. In the rehabilitation training, for example, it is important that the therapists inform the family that the exercises at home don't always represent a good solution, due to some conflicts, difficulty, uneasiness and suffering for the aphasic client. The autonomy of the client, must be encouraged, guided, never forced. The motivation for the autonomy is a long process involving many factors (cultural, social, economical, psychological…) Another important aspect the therapist must take into consideration, is the psychological world of the client. As they have communicative problems, they tend to isolate themselves and, therefore, they live a solitary life. This way of living causes a depression state and the first signs are: tiredness, sleep and appetite disorders, aggressiveness, psychomotor slowing down. This kind of reaction may indicate an affective discomfort and it is, therefore, necessary a prompt treatment. In some cases, there are deficits, such as temporal-spatial disorientation, loss of memory and attention, , which may be signs of mental deterioration which requires diagnostic analysis.

LIFE FOR THERAPY

At the end, we think useful the operators dialogue with their clients, particularly, those who they support for long periods of treatment, about the matter of the risk of " living for the therapy". It's better for them to consider the therapy a flexible, useful, but not infallible tool, and not suitable enough to represent the whole reality.