Article Type : Short commentary
Authors : Mario Souza y Machorro
Keywords : Neurosciences; Addictive disorders, Clinical approach, Resilience, Personality; Etiopathogenetic, Psychopathology
The
advancement of contemporary imaging that supports the development of neurosciences
is the expected paradigm of mental pathology recommended by the WHO. Such
advancement and clinical experience reinforce the conceptual-operational vision
that replaces the traditional approach of the patient with addictive disorders
(alcohol, cannabis, cocaine, fentanyl, etc.) and mental disorders -which have
never been mutually exclusive-, with a new and broader vision oriented to a
detailed, unconditional, and efficient approach. Evidence on addictive
pathology, located at the molecular and cellular level of body systems and
their behavior,converges on the notion of "abduction of neural mechanisms
linked to learning and memory," which under normal condition contribute to
survival. This evidence now better studied, provides an explanatory model of
people's resilience and vulnerability, derived from patterns of brain responses
and other nervous mechanisms that mediate reward, fear, conditioning or
extinction responses of adaptive social behavior and behavior, as prominent
traits of the personality, possibly associated with the
resistance/vulnerability that derives from the vital circumstantiality, in
front of certain objects-stimulus. This condition could be equally valid, with
respect to the effects of the etiologic-pathogenic consideration, of the
mechanisms involved in the origin and maintenance of the psychopathology of the
psychiatric patient.
The current complementary conceptual-operational vision, which
replaces the traditional approach to patients with addictive
disorders or mental disorders -which if they were mutually
exclusive-, proposes a new and broader vision aimed at a detailed,
simultaneous, and efficient clinical approach [1]. The common
pathway of addictions is that the different substances
administered in an individual directly or indirectly produce an
unnatural increase in dopamine levels above normal.
The addiction process is mediated by a common pathway related
to dopamine and other neuroreceptors, whose increased release in
the ventral tegmental area raises their levels in the CNS [2].
Substance dependence is defined by the individual's need to take
some psychotropic substance with a high level of abuse and
dependence, in such a way that the substance progressively
centralizes the individual's life, which will end up altering their daily life, at the expense of the consumption of the same and/or
others, despite presenting clearly harmful effects. Similarly, it
occurs in the processes described as addictive behaviors.
Clinically it is characterized by the following signs and
symptoms: dependence, tolerance, abuse, sensitization, and
withdrawal syndrome. Such a set, related to the functioning of
dopamine located at the molecular and cellular levels of the body
systems and its peculiar behavior, converge in the notion of
"rapture of the neural mechanisms linked to learning and
memory", which under normal conditions contribute to survival
[3].
Contemporary documentary evidence provides an explanatory
model for the Resilience and vulnerability of people, which
ideally would facilitate their social reintegration, derived from
certain socio-family and individual conditions and patterns of
brain responses, as well as other nervous mechanisms that
mediate reward responses, fear, conditioning or extinction ofbehavior and adaptive social behavior, as important personality
traits. Which are associated with the resistance or vulnerability
coming from the vital circumstantiality of everyone, in the face of
certain stimulus-objects [4,5]. It has been corroborated by fMRI
studies and genetic testing that dependence, the most severe form
of substance use disorder, is a chronic brain disorder shaped by
biosocial factors with devastating consequences for individuals
and for society. The understanding of the addictive disorder has
advanced significantly in recent decades, in part due to the great
advances in genetic research, neuroscience and the development
of new technologies, analytical tools for molecular changes in
specific neuronal populations in experimental animal models, as
well as brain imaging devices to assess brain function and
neurochemistry in humans. These advances have illuminated the
neurobiological processes through which biological and
sociocultural factors contribute to resilience or vulnerability to
drug use and dependence [6]. Delineation of neurocircuitry
disrupted in the addictive process, including circuits that mediate
reward and motivation, executive control, and emotional
processing, has provided insight into aberrant behaviors displayed
by comorbid addicted patients and provided new goals for
treatment. Most prominent to this effect are disruptions in an
individual's ability to prioritize behaviors that result in long-term
benefit over those that provide short-term rewards and increasing
difficulty in exercising control over their behaviors, even when
associated with catastrophic consequences [7]. These advances in
understanding brain development and the role of genes and the
environment in brain structure and function have built a
foundation on which to develop more effective tools to prevent
and treat addictive disorder [8,9]. This could be equally valid for
the effect of the etiopathogenic consideration of the mechanisms
that may participate in the origin and maintenance of the
psychopathology of the psychiatric patient [10].
Resilience of the comorbid addicted patient. The term Resilience
It comes from the Latin word Resilio, interpreted as the
"Universal human capacity to resist highly stressful situations or
adversities", for which it is considered part of the evolutionary
process of the human being, in its favour [11]. Both terms
involved in the phenomenon, emanating from physics, present
important differences: On the one hand, Toughness (stored energy
per volume unit) grants the susceptibility to deform a material
until it breaks; on the other hand, Resilience (energy per unit
volume that can be absorbed within the elastic zone of the
material in question) does not give rise to permanent deformation
or its rupture [12]. Resilience represents the process of adequate
adaptation to adversity, trauma, tragedy, threat, or significant
sources of stress experienced in life, such as family problems,
personal relationships, serious health alterations and various
stressful work or financial situations, among other. A Resilient
individual is one who, without ceasing to experience difficulties,anxiety or depression, etc. -at the moment or even some time
later-, in the face of adversity, their emotional pain, sadness and
other reactions -common in those who have suffered great and/or
serious negative situations or traumas in their lives- experience a
better handling of the situation and less unfavorable consequences
than those who did not know, could not or did not adequately
have biopsychosocial experience and resources for this purpose
[12,13]. The concept of Resilience by extension -used in the fields
of sociology, anthropology, psychology, and other sciences that
study man-, also refers to the characteristics of people that include
behaviors, thoughts and actions, which can be learned and
developable by anyone; hence, a wide range of factors contribute
to its development. It has been documented that one of the most
important factors of Resilience is living loving and supportive
relationships that converge on the concepts of J. Bowlby,
regarding the secure attachment in childhood within and outside
the family [14,15]. The importance of the Attachment Theory,
widely corroborated in the clinic and in the literature on the
subject, lies in the innate tendencies that regulate the way in
which the human being responds to threats, danger, and losses,
closely related to the way in which Establish relationships with
significant others. Therefore, such behavior is organized through
brain control systems related to protection and survival functions
[13,14]. In such a way that children who develop positive
interaction with their caregiver internalize the sense of security
that allows them to expand their emotions. This Secure
Attachment (when the caregiver shows affection, protection,
availability, and attention to the baby's signals), allows him to
develop a positive self-concept and a feeling of trust towards
himself and others. Later, when interacting, such people tend to
be more warm, stable, and satisfying intimate relationships, and
intrapersonal, they tend to be more positive, integrated and with
coherent views of themselves. Unlike Anxious Attachment (when
the caregiver is physically and emotionally available only on
certain occasions, it makes the individual more prone to
separation anxiety and fear of exploring the world), such people
do not assume trustworthy expectations regarding access and
response of their caregivers, due to the inconsistency of emotional
skills. In them, the ambivalence appears between a strong desire
for intimacy and a feeling of insecurity with respect to others.
Avoidant Attachment (when the caregiver constantly ignores the
child's signals of need for protection, it is experienced as
rejection, which does not allow him or her to develop in a
desirable way the feeling of trust required for human interaction).
This makes such people feel insecure towards others and expect
to be rejected again, according to their previous experiences of
abandonment [13]. Relationships that emanate love and trust, that
simultaneously provide role models, that offer encouragement and
security, are considered to contribute to affirming individual
resilience. Other associated factors are a) The ability to makerealistic plans and follow the necessary steps to carry them out; b)
A positive view of oneself, and confidence in one's own strengths
and abilities; c) Skills in communication and problem solving,
and d) The ability to handle strong feelings and impulses in terms
of better techniques for coping with problems. All of them are
factors that people can develop by themselves or, where
appropriate, with specialized help for this purpose [12-14].
Resilience entails maintaining flexibility and balance in life as
difficult circumstances and traumatic events are necessarily
confronted. Therefore, the important thing to mention for the
purposes of this communication is that it can be achieved, by
those who did not acquire it naturally, in different ways, using
some methodological guidelines used in psychotherapy that seeks
to reconstruct the personality: a) Allow yourself to experience
strong emotions and recognize at the same time, when you have
to avoid them in order to continue functioning; b) Be proactive
and seek to get ahead with optimism; c) Take actions to address
the problems and face the demands of daily life; d) Going back on
occasions can be beneficial for the purposes of a reorganization
and planning of the new confrontation of the problem in question,
now with new energy; e) Spend quality time with loved ones
waiting to share concerns and perhaps receive support,
encouragement and care that lead to trust in others and in oneself
[13]. Given that resistance against destruction allows the
development of the ability to protect integrity under vulnerable
conditions of tension, regardless of their origin, resilience is also
appreciated as the: “Capacity to build a positive and socially
accepted vital behavior despite the difficult circumstances.
Achievement derived from the combination of protective factors
that allow an individual to face and overcome the problems and
adversities of life”. Similarly, it was visualized and extended to
group dynamics, described as: "The ability of a person or a group
to develop well, to continue projecting into the future despite
destabilizing events, difficult living conditions and trauma.
sometimes serious” [14,15]. Since ancient times, the term is
estimated as resulting from the interaction of the individual with
the environment, his family and his living conditions, considering
vulnerability the starting point for the emergence of Resilience,
which is not absolute, total or permanent, but dynamic and
evolutionary, since the response depends on the type, frequency
and intensity of the trauma and its interpretation, according to the
circumstances, cultural context of the trauma and stage of life in
which it affects individual subjectivity [16]. Such a condition
results from the interaction between protective factors and risk
factors depending on personal characteristics and their
sociocultural context [15,17].
Vulnerability to disease or other alterations that act on the body's
economy is associated with the psychological resources available
and with the ability to activate in stressful situations, such as real,
constant, immediate, or delayed sensitivities and weaknesses[18,19]. The condition of invulnerability is taken as: “Strength,
ability to resist stress, pressure, and potentially traumatic
situations. But there will always be a risk, referring to the
uncertain and variable result in the face of the individual's
confrontation with internal or environmental stress. It is a
perceptible phenomenon in which, at a certain level of stress, it
can immediately result in maladaptive behaviors [20,21]. In the
seventies, the term “invulnerable” was used as a synonym for
resistance, referring to the robust constitution of a subject. But in
various investigations it was observed that certain groups of
children and adolescents manage to overcome adverse situations,
without suffering serious psychosocial sequelae and therefore
they were referred to with that adjective. However, resistance to
stress is always relative and variable, according to the stage of
development and the psychophysical strengths that it includes, as
well as the quality of the stimuli to be faced [20,21]. The elements
identified in different contemporary studies, regarding the
"biological equipment" of individuals to face highly stressful
events, created the concept of "empowerment", which has almost
always been related to factors derived from protection initial
maternal-infant and its effect throughout life. However, it should
be emphasized that since resilience is never absolute, total, and
permanent, it must be assumed because of vital evolutionary
processes in which the transcendence of a trauma due to its
characteristics can exceed the individual's resources to the point
of overthrowing it. This condition tends to vary according to the
circumstances, nature, context, and emotional maturity of the
individual, which tends to express itself in different ways among
different cultures, modified by individual and group traits [22].
A group of characteristics related to resilience have been
documented : a) Initiative, ability to face problems and exercise
adequate self-control; b) Humour, the ability to laugh at oneself,
to find the comical and laughable in adversity; c) Creativity,
activity that starts from chaos and disorder and manages to give
order and purpose to acts; d) Morality , capacity for moral
conscience that allows discernment between what is good and
what is socially accepted bad; e) Introspection and independence,
establishment of limits with oneself and the surrounding
environment, with adequate emotional and physical distancing,
without reaching isolation; f) Ability to relate to others, social
ability to interrelate intimately and satisfactorily due to the need
for sympathy and the ability to offer oneself to others. Ad hoc
investigations have also pointed out some complementary
protective factors associated with Resilience that are usually
interpreted in the same desirable line of natural and acquired
development: a) Favorable development of Self-esteem, b)
Attained sociability, c) Sense of humor, d) Availability of a Life
Project and e) Participation in the life of the people of the
Community Support Networks [23,24]. Risk Factors have also
been described, which, known for their psychophysical impactare related to vulnerability-Tenacity: a) Addictive disorders in the
parents; b) Marital separation or breakup of the parents; c) Death
of one or both parents; d) Presence of family conflicts; e)
Existence of family violence; f) History of physical or sexual
abuse; g) Poverty and restrictive circumstantiality; h) Serious
and/or chronic illnesses and i) Disasters, whether natural or war,
among others [25].
The existence of certain family and social traits that act by
modulating the resilient phenomenon, paradoxically, support the
professional management of acute, post-traumatic, addictive or
comorbid mental disorders of various kinds, such as when the
family decides to participate in a treatment or in the rehabilitation
and social reintegration maneuvers of any of its members: a)
Favorable temperament of the parents; b) affective cohesion of
the family; c) Constant qualitative support to the children; d)
Useful presence of support structures outside the family nucleus -
teachers, church, substitute father/mother, support institutions,
etc.-, and e) Positive peer relationship [26].
The resilience and its individual and collective scope, derives
from an active, productive and constant action [27,28] requires: a)
Building favorable and close family relationships, friendships and
other important people in life, from whom you can accept and
offer support, as well as those people who participate in
community groups from their different approaches, ends and
positive purposes of mutual benefit; b) Avoid the negative
consideration of things, by a predisposed and insurmountable
vision of adversity. Although no one it can prevent the occurrence
of events that produce a great load of psychophysical and social
tension, it can change the way of observing and interpreting them,
especially the way of reacting to them; c) Accept that change is
part of life, it becomes fundamental for the required vision of
disposition, adaptation and management of changes, particularly
when they are necessary; d) Accept the circumstances that cannot
be altered and focus on the circumstances that make it feasible to
modify; e) Effectively mobilize actions in favor of the proposed
desirable goals; f) Carry out effective actions and omit the
iterative consideration of the obstacles and their consequent
tensions; g) Seek new opportunities for self-discovery, improving
self-esteem and developing a better appreciation of life; h)
Cultivate a positive view of oneself through the development of
confidence focused on the ability to address and solve problems,
based on confidence in one's own resources; i) Promote an
objective and clear vision of the prevailing reality and its future
perspective; j) Maintaining the hope of solving the problems,
allows visualizing what is wanted, rather than increasing concern
about what is feared; k) Taking care of oneself favors the
effective satisfaction of needs, promotes interest in activities and
favors the arrival of positive situations. Which requires a personal
style to establish relationships and restore self-confidence [29,30].Between the state of health and the resilient individual capacity as
the most desirable social phenomenon -motivated by individual
and group characteristics-, the prevention of disorders and the
social reintegration of the comorbid addicted patient,
indispensably mediate timely and adequate treatment [31-34].
And for this to take place and be effective, different obstacles and
limitations must be overcome to access the health institution,
whose multiple difficulties pose a serious threat against the
provision of professional assistance [35], both by applicants due
to its characteristics, as well as those of the institutions that grant
it [36-37]. This includes, just to mention a few limiting elements,
the clinical requirements and the systematization of the necessary
knowledge, applied to the current and past health status of the
user, through the correct application of propaedeutic and
nosologically methods of systematized standardization , the
essential record of the clinical history, the important antecedents
linked to the case, the presumptive and definitive diagnoses, and
its convenient management provided according to the experience
and current documentation available for this purpose, which not
all health institutions in the country, by the way, carry out, not in
the same way [38-40].
The concept of social reintegration implies a whole process and
the degree of rehabilitation achieved, which requires evaluating
the application of a programmed management, which begins
previously with awareness and information strategies for the
community, as well as strategies for the timely detection of the
cases. This process must include at least: a) A complete joint
diagnostic assessment of the addictive and psychiatric problems
of each patient; b) The elaboration of care plans with objectives
established by the hierarchy of the health needs of the users and c)
All this within the contextual framework of a defined structure
and duration contained in the program carried out [41,42].
Programs that dispense with such characteristics -such as the
multiple plans and "programs" of associations, groups and nonprofessional organizations that operate in our country, with the
discretionary endorsement of the State-, cannot be considered
useful for an adequate rehabilitation to long-term and the social
reincorporation of those affected, as long as they do not show
documentary efficacy of their results, given that they often fail to
meet the clinical requirements of patients with concurrent
addictive and mental diagnoses [43].
The coexistence of addictive disorders with mental disorders
observed for four decades in the practice of the specialty is at
least 20% to 50% in mental patients in general and between 50%
and 75% in specialized addiction units. Other epidemiological
data suggest that 60% of psychiatric patients show comorbidity
due to addictive disorders compared to 6% in the general
population, which even impact the field of medical education in
the specialty [44-47], where there is a deficiency in the
preparation formal, reflected among other things, in the comorbidaddictive disorder that often remains undiagnosed [48-50]. The
range of services offered to the community by organizations and
institutions must guarantee an adequate functioning of their units
through their human resources, with quality activities supervised
by the respective health authority. The therapeutic intervention
supposes the understanding and knowledge of the concurrence of
addictive and mental disorders -which can be located between
30% and 90% of the cases, depending on whether it is one or the
other type of disorders and their combination, which roughly
requires proposed way, of carrying out the following activities: a)
Evaluation, delimitation and initiation of the problem; b)
Formulation and control of hypotheses; c) Target selection; d)
Specification of the participating variables; e) Programmatic
treatment (according to the real availability of the units for this
purpose); f) Evaluation of the process and its results; g)
Monitoring of the results achieved and modification where
appropriate. To this end, it is considered essential to locate, define
and evaluate the motivational stage in which each patient is, to
direct him towards a stage of change that enables him to make
decisions and reincorporate, where appropriate, to an ad hoc
treatment [51-54]. To comply with these approaches, it is
recommended to develop: a) Training, updating and continuous
clinical supervision programs for the staff; b) Epidemiological,
clinical and sociomedical research activities; c) Systematic
dissemination of the results obtained from the treatments
provided, which feed back into the current programs or, if
required, their pertinent modification [55]. The results and
consequences obtained from such management of both types of
comorbid disorders, will be whether or not, a better channeling to
the purposeful restoration of the referred morbid condition is
possible. Once the impediments have been cleared, there is an
initial possibility of restoring the damage and its consequences to
the extent that individual and institutional possibilities allow it, so
that the rehabilitation maneuvers try to achieve the functionality
that was had or that required for the case, depending on the case.
Be this, at the service of an adequate final social reincorporation
or, failing that, in those patients never inserted, their productive
inclusion in the community [56-57]. The importance of
psychopharmacological management must invariably be related to
the global evaluation and diagnosis of the case, as part of the
therapeutic plan. The circumstantiality given by comorbidity
requires that the biological, psychological, and social planes
coexist in the treatment, identifying the need to intervene from a
multidisciplinary, complementary, and synergistic perspective.
Psychotherapy carried out using procedures and techniques
appropriate to the different types of addictive and psychiatric
problems and their consequences, is a useful and indispensable
tool [55,58]. It is convenient to spend the necessary time to
motivate the comorbid addicted patient to receive treatment,
instead of imposing any therapeutic intervention. If we start fromthe recognition of the scarcity of resources and the diversity of
theoretical-practical frameworks that support the implementation
of various "therapeutic- rehabilitative " alternatives, it is essential,
not only pertinent, to establish a common national front to
coordinate efforts and obtain the best long-term results [58,59].
Rehabilitation of the comorbid addicted patient. It is the pinnacle
of all the management provided to patients for their disorders,
without it the effort and achievements achieved are lost. To
properly understand and develop rehabilitation, it is necessary to
consider the person in their environmental context [55,56].
Human behavior results from the interactions between their
abilities, their personality, and their environment, it is the
concrete integration of the man-middle dialectic. This allows us to
understand the person within their environment, influences and
determines the family, community, work, and ecology [34-36].
Rehabilitation incorporates essential elements to build a
comprehensive conception: a) The specific needs of the person,
the disability and capacity profiles; b) The requirements
established by the individual's environment; c) The provision of
specific support; d) The treatment and rehabilitation of the
comorbid addicted patient must be based on a multidimensional
conception that integrates the different triggering and consequent
factors, so that they form an integrated system of corresponding
therapeutic responses [56-58]. Although it is difficult to draw a
clear dividing line between treatment and rehabilitation and
between rehabilitation and social reintegration of comorbid
addicted patients. The treatment for example, brings together the
maneuvers that tend to correct the syndromic manifestations of
the pathology. Rehabilitation attempts to return the patient to his
or her original emotional and social functional roles. So that the
procedures require to go through the evolutionary overcoming of
several phases. The need for rehabilitation presupposes that some
personal and/or social dysfunction prevails, that it pre-exists that
of the concomitant disorders and that it is maintained during their
treatment, or even after achieving some functional operative
stability or healthy control [55-57]. So that the individual
competencies, which are activated for the restitution of the
affectation, are seen as the set of interventions tending to reduce
or eliminate the disability and the psychophysical handicap at the
same time. For several decades, the countries interested in the
problem have designed ad hoc programs so that patients with
mental disorders alone or with comorbidities develop their
capacities, to function as well as possible in their environment.
Such is the case of addictive and mental disorders, and those
others that present serious physical, mental or both limitations, of
various types and more especially, towards those that derive from
known psychiatric alterations [58-60]. The purpose of
rehabilitating is to help people develop the emotional, social, and
intellectual skills necessary to be able to live, learn and work in
the community, with the least possible amount of support fromhealth professionals. the different areas. For this, certain strategies
are used: a) That the patient develops the necessary skills for
interaction in a stressful environment; b) The aim is to acquire
and develop the necessary environmental resources to reduce the
potential stressors that impact human beings and patients to a
greater extent. Although rehabilitation in this field of addictive
and mental disorders, in general, does not reject the existence of
the impact caused by addictive (mental) illness and its
comorbidity, the truth is that rehabilitation practices have been
slowly changing the perception community of these types of
disorders. Fortunately, the training of such patients changed from
a disease ¬-focused model to a functional disability-focused
model [59,60]. It is documented that more than 50% of people
with severe mental disorders with comorbidity show complex
patterns of symptoms, difficult to categorize, and a history of
suicide attempt [25,31,34]. Therefore, health personnel must
consider: a) The real vital circumstances that the affected person
will possibly face in their daily life; b) Help patients identify their
personal goals; c) Define the personal costs and benefits
associated with the previously identified needs. d) Assess the
individual's willingness to change and the recognition of the Stage
of Change in which they find themselves to facilitate their
participation e) Focus ¬rehabilitation planning on the strongest
areas of the patient and the stigma that affects them [61,62]. The
objectives are: a) Restore ¬hope in those who suffer a significant
alteration in their self-esteem as a result of their disease and
comorbidity, its complications and concomitants; b) Respect and
protect their rights; c) Increase the efforts made to be directed to
self-determination and its responsibility, regarding the
therapeutic- rehabilitative process ; d) Incorporate these values
into the concept of overcoming , where the ¬Therapeutic Alliance
plays a decisive role in ¬getting the patient to participate in
planning their care; e) Promote recovery from chronic diseases,
aimed at greater life satisfaction and the enhancement of the
ability to overcome vital stressors [63-65]. So, if the stated
objectives are added, rehabilitation essentially becomes an
exercise ¬in building social networks. It should be noted that the
perspective held that ¬addictive and mental illness, its clinical
manifestations, behavior and therapeutic adherence, etc., of
comorbid patients, are only the result of the pathological process
per se, is partial and incorrect. Numerous studies have evaluated
stigmatizing attitudes against people with mental and addictive
disorders, and in recent decades, scientific interest in the
perspective of stigmatized individuals has increased. For
example, the negative consequences of stigma and perceived
stigmatization have been documented. Among them,
demoralization, decreased quality of life, lack of work and
reduction of social networks stand out [66-68].
A national treatment system for comorbid addictive and mental
disorders is essential in the country, to deal with this serious andgrowing problem, which represents at least a third of all cases
seen in the emergency room, which are added to the various tens
of thousands of consultations (outpatient, hospital and residential)
per year, granted by different organizations and institutions of the
country. However, the available efficacy of current therapy, the
different types of programs do not use the same methodology, and
their maximum variance, in terms of approaches, content and
effectiveness, are still not considered routine, the individual
characteristics of each patient as has been noted in the literature
for a long time by the WHO recommendation [69 -71]. The
reduced efficacy of certain approaches requires better
methodological selection and evaluation of the corresponding
indication, to use it, under supervised evaluation, the most
appropriate methods and clinical procedures for each problem.
The comorbidity of addictive disorders includes a wide
nosological range of mental disorders, which increases even
more, when joining the modalities and variants caused by the
addictive pathology and corresponding stigma [72-75].
Consequently, the good evolution of comorbid addicted patients
in the post-treatment period depends on different factors of
personal significance, which influence their adherence to
treatment and involve motivation and performance in scheduled
activities, which produces and maintains a documented
improvement. in rehabilitation and social reintegration. In
practice there are different difficulties for rehabilitation. In fact,
the need to practice rehabilitation on comorbid patients implies
the prevalence of some personal and/or social dysfunction that
pre-exists the addictive disorder that must be reduced, since it is
maintained during treatment or even after achieving stabilization
of their addiction. Condition and, where appropriate, abstinence
[76]. Such a situation of dysfunction, anomaly, or loss, which
characterizes this type of complex pathology, is frequently framed
by the theoretical concepts of disability and handicap mentioned
above. Conceptually speaking, this condition usually extends and
adheres to the goals of social reincorporation [77,78]. The design
of rehabilitation approach strategies must articulate the individual
and interpersonal spheres of patients in their social context. In
other words, it must tend to integrate both processes, that of
rehabilitation and another active and complementary process of
continuity -although it may be considered implicit-, social
reintegration [79,80]. With such a conjunction, one arrives at the
understanding of a more complete concept of rehabilitation,
whose goal is: " Reduce or eliminate the disability of comorbid
addicted patients through the development of new capacities and
reinforcement of diminished capacities, little developed or
conserved, that allow them to structure a self-sufficient and
satisfactory life system with stable control of their pathology and
without substance use”. Rehabilitation thus becomes an active
and extensive process where the patient abandons his passive role
as a patient and assumes –in the best of cases-, his responsibility to the extent feasible in the collective effort for the improvement
and improvement of his person. The biological, psychological,
and social areas and their capacities that are not diminished or not
yet developed, can be focused from an evaluation, to determine
the disabilities and their impact, or the influence on the others and
in this way structure a feasible and individualized for
rehabilitation. Therefore, together with the patient, a proactive
and realistic structure-commitment must be developed, with short,
medium, and long-term objectives and goals, as objective and
simple as possible. The more active the patient's participation and
the deeper the understanding of their problems and the benefits
they will obtain with the rehabilitation, the greater the possibility
of progress. The documented experience indicates that if the
concrete contribution of the community in the rehabilitation is not
considered, it will not be specified. The feasible links of support
(social networks) that the patient has established in his
environmental context should be investigated, as well as the
material resources and useful means in the development of
rehabilitation programs, which, to be real and successful, requires
of the operational conjunction of the individual and community
processes, since their integration is essential for the active
program, which must be gradual and clear with respect to the
needs and possibilities of each person [81-84]. Social
reincorporation of the comorbid addicted patient. The goal is the
active and permanent achievement of their roles and community
environment, through social participation, which allows those
affected to have a favorable environment, so that they can use
their "new" capacities and personal resources, lead him to assume
his responsibilities and face the situations of his daily life.
Therefore, its elements represented by the groups, networks,
associations, and organizations that can contribute to the
achievement of the ultimate objectives of rehabilitation become
transcendent [80,81]. Actions are all those activities that lead to
exercise; the "normal" functions that offer elements for an active
contact with reality and those that lead the patient to propose and
practice a daily life without drug use and having controlled or at
least modified the mental symptomatology. The role played by
this work will be a decisive part of comprehensive rehabilitation,
as it is essential for the improvement and maintenance of selfesteem and self-confidence of comorbid addicted patients, and
becomes an essential part of their aspirations, to replace a life
affected and with a gloomy prognosis due to a productive activity
outside the risks involved in the consumption of psychotropic
drugs. This includes directing and stimulating the patient to the
conquest of a new productive capacity [85-88]. Given the
consideration that people's problems are not only individual or
internal, the solutions reside in the interpersonal systems that
involve each other, social networks, are nothing but the
description of certain interactions that establish a certain number
of people. The congruence between any living being and its environment is called Adaptation. This requires that the
ecosystem maintain its consistency, maintain its adaptation,
organization, and existence. As the construction of exchange and
interaction (network) established by living beings, constitutes the
medium and therefore, its realization as a living being, people's
problems cannot be seen only as individual or internal. On the
other hand, the existence of an unconscious problem pending
resolution, that is, intrapsychic, is not ruled out, which must be
addressed at some point and in parallel when the conditions for it
are met. In some cases, it may occur as part of the
psychopharmacological and psychotherapeutic management of
their underlying disorders. In other cases, certain people do not
meet the requirements (awareness of illness, interest, willingness
to change, ability to think in psychological terms, reflection, or
insight, etc.), for the required psychological analysis, so should be
set aside after a proper evaluation in that regard. In fact,
rehabilitation, due to its special reconstructive characteristics, is
part of considerations about the desire, capacity, and power of
people to overcome the disease and its consequences, so that its
procedures could facilitate the transit through the analysis of the
conflicts experienced and the produced and current problems, for
the improvement of their vital condition. This can be used in
some patients for the self-discovery of their psychic potentialities
and their self-actualization, as well as for a possible attitudinal
and behavioral change in this regard. To this effect, it is necessary
to emphasize here that rehabilitation does not apply only to the
physically handicapped, but rather this concept extends to all
patients who need to overcome and overcome their failures,
deficiencies, or sequelae of any kind. For this reason, although the
solutions basically reside in the interpersonal systems that link
them together, they do not exempt or limit the task of
investigating oneself and oneself with the support of a
professional. Social networks, a description of certain interactions
established by a certain number of people, refer to a group in
terms of a dynamic entity in constant evolution over time and the
circumstances in which it finds itself at a given moment,
depending on whether they are modified its features and functions
[89-91].
Social reintegration, also called reinsertion, or initial insertion in
its case, it is expected that it be active and permanent in its roles
and community environment -with the support of the participation
of the community-, so that it allows the individual to have a
favorable environment for the use of their "new" individual
capacities and resources that lead him to assume responsibilities
and face the situations of his daily life. For example, in the case
of those who have committed a crime [92,93]. For this purpose, it
must be possible to count on the different participating elements
of the different groups and organizations, focused on the same
purpose. Hence, specific actions have been planned to achieve,
through activities that lead to: a) Exercise of “normal” functions that offer elements for an active contact with reality; b) Activities
that lead the patient to propose and practice a daily life with
adherence to the treatment of addictive and mental disorders; c)
Work, essential for people's self-esteem and self-confidence, is an
essential part of the aspirations to replace pathology with a social
and productive life; d) The strengthening of the adaptive capacity,
includes directing and stimulating the patient to the conquest of a
new productive condition [94,95]. With this vision of active
process, the patient is persuaded to abandon his passive role as a
patient and assume his responsibility in the collective effort for
the improvement and improvement of his person. The areas
(biological, psychological, and social) and their capacities can be
focused from an evaluation, to determine the disabilities and their
impact or influence on the others and thus structure the respective
program. A structure with objectives and goals in the short,
medium, and long term, as objective and realistic as possible,
should be developed together with the patient. The more active
the patient's participation and the deeper their understanding of
the problem and the benefits to be obtained, the greater the
possibility of progress. If the concrete contribution of the
community in the process is not considered, it can be restricted to
the point of being able to materialize. Likewise, the links
established by the patient in their environmental context (social
networks), as well as the material resources and useful means in
the development of the programs should be investigated. The
process of improvement and change of circumstances, as well as
the resources and resources for its success, require that the
individual and community processes be integrated into an active,
gradual, and clear program, adapted to the needs and possibilities
of each person supported in the management
psychopharmacology and the psychotherapeutic process [12-16].
As people's problems cannot be only individual or internal
(intrapsychic), solutions are based on interpersonal systems that
involve them among themselves, although they are not perceived
that way (extra psychic). Social networks are the description of
certain interactions that establish a certain number of people. The
adaptive consistency of human beings is a paradigm and if an
ecosystem maintains its consistency, it will maintain its
adaptation, organization, and existence. Hence, the construction
of exchange and interaction (Network) that people establish
constitutes the medium, and, therefore, its realization as a living
being. This provides certain favorable interactions for its
members in its everlasting temporo-circumstantial evolutionary
dynamics, depending on how its characteristics and functions are
modified [91-93]. The provision of services to the community and
large population centers, as well as to certain other groups
(children/adolescents, the elderly, pregnant women, patients with
HIV-AIDS, groups in prison, the disabled, indigenous people,
among others). They have been neglected for a long time, so the
members who take refuge there for lack of better institutional assistance will have to be included. Consequently, the
mobilization of the network, as a cooperative support system, an
access route to the growth of people's capacity for self-affirmation
and self-independence, should be focused on those who most
require it [93,94]. In this context, both the therapeutic intervention
and the Social Network enable the transformation of the personobject into a person-subject through the self-esteem achieved by
the process [91-94].
Conclusion. Advances in the understanding of addictive disorders
and other concurrent mental disorders suggest that both
alterations should be part of public health policies -as an
obligation of the State-, from Resilience to Social Reintegration,
as it is an imperative requirement of every individual affected on
your health. The treatment plan must be continually evaluated
and, where appropriate, modified to ensure that it keeps pace with
changes in the person's needs [95]. It is essential that the form of
treatment is appropriate to the patient's age, gender, ethnic group,
and culture and that it be continued during a personalized
observation period [47-49]. For many patients, medications form
an important element of treatment, especially when combined
with different types of therapy. From the perspective of the social
reintegration of those affected, the intervention is the
responsibility of the whole society, so the approach includes the
areas: family, educational, work, and free time management, in
order to implement social support networks and monitoring of the
course of comorbid addictive disorder and long-term withdrawal
[6]. It is about helping the patient from an ambitious vision to
better understand and recognize their behavior in relation to their
disease and with the rest of society, so the counseling sessions
should focus on issues related to health in all its aspects, family
relations, professional training, labor reintegration, housing
support and other legal matters [94,95].
All comorbid addicted patients are expected to achieve full
reintegration: a) They must recover their resilience, so they must
build strong and positive relationships with loved ones and
friends to obtain support and acceptance in good/bad times, b)
Establish connections with the community, c) Make each day
have meaning and carry out everything that gives a sense of
achievement and daily purpose, d) Establish goals that help to
look towards the future with meaning, e) Learn from experience,
f) Assess how difficulties have been faced in the past, g)
Remember the skills and strategies that helped in difficult times,
h) Keep hope, i) Faced with the impossibility of changing the
past, you can always look to the future, j) Accept and even
anticipate change, facilitate adaptation and look at new challenges
with less anxiety. Therefore, it is imperative that: a) You must
take care of yourself, attend to your own needs and feelings, b)
Participate in activities and hobbies with enjoyment, routine
physical activity, sleep well, maintain a healthy diet, c) Practice
stress management in all its forms, d) Be proactive withoutignoring the problems, face them through a participatory action
plan, e) Recovering from a big setback, a traumatic event or a
loss, takes time but you must trust that the situation can improve
if you work on it. 34-36 In complementarity, it is necessary for
health personnel to understand the dimension of the problem
faced by each person, learn, and teach the patients in their care the
common language of health, attend to it, manage it and promote it
in the context of their profession and from the most basic social
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