El rol del psicólogo en el ámbito de la salud mental.

Imagen de clbustos

Informe realizado por Javier Ardouin, Claudio Bustos,
Catalina Fernández, Rosa Gayó y Mauricio Jarpa (2000)

Indice


1.- Introducción. *

2. - El rol del psicólogo en relación a la psiquiatría *
2.1. - Enfoque diagnóstico-evaluativo(psicométrico) *
2.1.1. - El modelo médico aplicado al comportamiento anormal *
2.1.2. - La labor del psicólogo dentro del enfoque de la "enfermedad mental". *
2.1.2. - Evaluaciones psicométricas *
2.1.2.1. - Pruebas proyectivas *
2.1.2.2. - Pruebas de inteligencia: escalas de Weschler. *
2.1.2.3. - Escalas de diagnóstico y personalidad: MMPI *
2.1.2.4.- Pruebas de organicidad. *
2.1.3.- Crítica al modelo diagnóstico-evaluativo *
2.2.- Enfoque terapéutico integrado. *
2.2.1.- Enfoque alternativos de evaluación y tratamiento de la conducta anormal *
2.2.1.1.- El modelo EVAC o de estrés-vulnerabilidad-afrontamiento-competencia (Liberman, 1993) *
2.2.1.2.- La Evaluación conductual *
2.2.1.3.- La Psicología Comunitaria *
2.2.1.4.- La función del psicólogo en el ambiente de la salud mental. *
2.2.2.-Vías de intervención del psicólogo en los problemas psiquiátricos. *
2.2.2.1.- Adiestramiento en habilidades sociales. *
2.2.2.2.- Intervención en la familia *
2.2.3.-Rol del psiquiatra y el psicólogo en distintos trastornos conductuales. *
2.2.3.1- Depresión *
2.2.3.2.- Esquizofrenia-psicosis *

3. - La labor del psicólogo en Chile *
3.1. - Antecedentes. *
3.2. - Importancia de la psicoterapia en el tratamiento de las enfermedades mentales. *
3.3. - Brecha entre recursos existentes y recursos requeridos. *
3.4.- Modelo de funcionamiento de los sistemas de Salud Mental en Chile. *
3.5. - Propuesta de programa nacional de salud mental y la labor del psicólogo dentro de él. *
3.5.1. -Características generales del programa. *
3.5.2. - Actividades del programa *

4. -Actividad práctica. *

5.- Discusión y conclusión *

6.- Referencia bibliográfica *


1.- Introducción.

La psiquiatría como ciencia reconoce los aportes de la Psicología, que deben ser tomados en cuenta a la hora de comprender e intervenir en algún tipo de disfunción o problema psicológico; es así como Kaplan (1997) establece como una de las proyecciones futuras de la psiquiatría: " la comprensión de las emociones y la conciencia también amplia el enfoque de la psiquiatría para analizar la experiencia subjetiva humana. Las herramientas clínicas, desde los fármacos hasta la psicoterapia profunda, podrían encontrar mayores aplicaciones a medida que se sepa más acerca de los cambios psicológicos" (p.266). Pero también el autor reconoce que el intercambio de conocimiento debe realizarse en ambos sentidos, ya que la psiquiatría tiene mucho que ofrecer a la psicología en lo referente a aportes neurofisiológicos y anatómicos.

Desde esta perspectiva, estarían bien delimitados los campos de conocimiento reservados a la psicología y a la psiquiatría, pero en lo referente a la actuación práctica de cada profesional, esta clara delimitación y asignación de tareas se hace bastante confusa.

En el presente trabajo, abordaremos las dos perspectivas acerca del rol que debe desempeñar el psicólogo: el psicólogo como profesional evaluador, "testómetra", a quien le corresponde la aplicación de instrumentos psicométricos de diversa índole para precisar el diagnóstico psiquiátrico y suministrar información complementaria, y el psicólogo como un profesional más activo dentro de la dinámica preventiva y de tratamiento de los problemas psicológicos.

En relación a la primera perspectiva, el psicólogo suministra tests psicológicos a pacientes, derivados por el psiquiatra, siendo esto parte del proceso evaluativo y diagnóstico psiquiátrico. Estos generalmente se refieren a test de inteligencia (WAIS o WISC), tests proyectivos de personalidad (como Rorschach, TAT) u otras escalas escalas psiquiátricas como el MMPI. La finalidad de la aplicación es de tipo diagnóstico y también para controlar la eficacia de los esfuerzos terapéuticos.

En cuanto a la segunda perspectiva el psicólogo es visto como el profesional más competente para realizar la psicoterapia y como un importante agente de apoyo para las familias de los pacientes. Es así como el psicólogo formando parte de un equipo multidisciplinario realiza adiestramiento en habilidades interpersonales en distintos tipos de pacientes. Dentro de esta misma perspectiva, el psicólogo juega un rol importante dentro del hospital psiquiátrico cuando existe la intención de mejorar el ambiente del hospital, ya que puede cooperar en la consecución de una mayor interacción espontánea entre los pacientes y el personal, una mayor participación de los pacientes en su tratamiento, y una mayor libertad de éstos para deambular por la sala o el hospital.

 

 

2. - El rol del psicólogo en relación a la psiquiatría

2.1. - Enfoque diagnóstico-evaluativo(psicométrico)

2.1.1. - El modelo médico aplicado al comportamiento anormal

Desde el punto de vista psiquiátrico, los comportamientos desviados son considerados como "enfermedades mentales", o sea, como entidades con una evidente etiología biológica con factores causales necesarios y suficientes, de los cuales dependen, sin duda, los síntomas y signos. Una enfermedad se caracteriza porque, sin tratamiento, presenta un desarrollo invariante, predecible y responde también de un modo previsto a los tratamientos del caso.

Como postulado básico de este modelo, se considera que un importante número de problemas psicológicos deben ser calificados como enfermedades mentales, sosteniendo que cada trastorno mental constituye una entidad claramente delimitada, con características clínicas que constituyen síndromes diferenciados cualitativamente del funcionamiento sano (Martínez, 1998b).

Con el fin de generar diagnósticos confiables y válidos, se han creado diversos sistemas clasificatorios, entre los cuales destaca el CIE-10 y el DSM-IV. Este último, aparecido el año 1994, se caracteriza por su el uso de criterios operacionales, un sistema multiaxial de diagnóstico y una fuerte base empírica(Martínez, 1998a).

2.1.2. - La labor del psicólogo dentro del enfoque de la "enfermedad mental".

Atendiendo al modelo de la "enfermedad mental", podemos señalar distintas tareas que le corresponderán a las personas relacionadas con el ambiente de la salud mental:

  • Diagnosticar o rotular los comportamientos inadecuados dentro de una categoría noseológica determinada.
  • Tratar la enfermedad, especialmente los aspectos biológicos.
  • Evaluar los resultados del tratamiento.

Dentro de esta perspectiva, el psiquiatra sería el encargado principal de realizar estas tareas, siendo ayudado por otros especialistas en su labor. Al psicólogo, entonces, le correspondería por un parte ayudar en el diagnóstico señalando características del paciente tales como inteligencia, personalidad, presencia de organicidad, etc. - evaluación psicométrica - y, por otra, evaluar los resultados del tratamiento a través de las mismas pruebas psicométricas. Como se ve, al psicólogo no le corresponde directa responsabilidad en el tratamiento, sino que sólo evalúa determinadas características del paciente que pueden influir en el tratamiento o algunos de los resultados que éste ha provocado en el paciente. A lo más, el psicólogo puede realizar tareas de "psicoterapeuta auxiliar", siempre supeditado a la dirección del médico(Martí-Tusquets, 1982)

2.1.2. - Evaluaciones psicométricas

La evaluación psicométrica es aquel tipo de evaluación realizada en base a test, escalas o cuestionarios, las cuales se caracterizan por ser instrumentos sistemáticos y tipificados que comparan la conducta de 2 o más personas, siendo su utilización estandarizada y para los cuales se han elaborado normas, es decir, para sus resultados existen parámetros con los cuales comparar.

Generalmente, la evaluación se hace en base a una batería estándar mínima de instrumentos, de tal forma que la evaluación está preestablecida y da resultados globales.

Supuestos de la evaluación psicométrica.

La conducta es función de una estructura interna estable del individuo, por lo tanto, se lleva a cabo una descripción, explicación y clasificación de los aludiendo a factores internos y se señala que el pasado aporta de modo substancial a la formación de la personalidad, la cual sería estable y consistente. Las conductas recogidas en el test son signos de los rasgos subyacentes a la personalidad.

2.1.2.1. - Pruebas proyectivas

Las pruebas proyectivas se caracterizan por la presentación de estímulos ambiguos, ante los cuales el individuo debe responder de acuerdo a su criterio, lo que implicaría la expresión de características personales en la respuesta; de este modo, se supone que los tests proyectivos pueden recoger información sobre la personalidad, motivaciones, formas de percepción, estado anímico, etc.

Existe un variado número de test proyectivos, entre las cuales se destacan el test de Rorschach y el Test de Apercepción Temática o TAT.

2.1.2.1.1. - Test de Rorschach

Fue diseñada por el psiquiatra suizo H. Rorschach en 1921 para la evaluación de la personalidad. Una prueba de Rorschach consiste en 10 tarjetas que exhiben diseños simétricos de manchas de tinta; las tarjetas son presentadas una a la vez a los sujetos, a quienes se les pregunta 1) que ven en las manchas y 2) que características de las manchas lo hacen ver eso.

Las manchas de tinta son consideradas estímulos apropiados porque son ambiguas, no son amenazadoras y no producen respuestas aprendidas; estas características aportan información valiosa sobre la actitud con que el paciente enfrenta las situaciones inestructuradas. (Kaplan y Sadock, 1997).

Existe una variedad de enfoques para interpretar y calificar las respuestas a este test. El más extendido y reciente es el de Exner, cuyo sistema de puntuación se basa en revisiones de los hallazgos de investigación y estudios de la técnica de Rorschach(Sue y otros, 1996). En general, entrega las características del procesamiento perceptivo y cognoscitivo del sujeto.

Si bien las propiedades psicométricas del test de Rorschach son limitadas, el procedimiento se está fortaleciendo en tanto los sistemas de codificación se hacen más específicos y los investigadores dedican más atención a la comprobación empírica de sus conceptos. La validez de la interpretación puede mejorar con el uso frecuente de la técnica y con la mayor experiencia clínica. (Kaplan y Sadock, 1997).

 

2.1.2.1.2. - Test de Apercepción Temática (TAT)

Fue desarrollado primero por H. Murray en 1935. Consiste en 30 tarjetas de dibujo, cada una de las cuales describe de manera típica dos figuras humanas. Sus poses y acciones son lo bastante vagas y ambiguas como para estar abiertas a distintas interpretaciones. Algunas tarjetas son apropiadas para ser aplicadas para todos los grupos, en tanto que otras son específicas para un solo sexo o edad. Como la técnica de Rorschach, el TAT entrega motivos, impulsos y procesos de personalidad subyacentes por medio de la proyección. La mayoría de los clínicos concuerdan, sin embargo, en que el TAT es mejor para describir aspectos de las relaciones interpersonales. (Sue y otros, 1996).

2.1.2.1.3. -Críticas a las pruebas proyectivas.

Estos instrumentos se caracterizan por una baja confiabilidad y validez. Se dice que presentan baja confiabilidad porque sus resultados dependen en gran medida de la capacidad, intuición y formación del clínico, de manera tal que si bien los resultados de la aplicación pueden ser útiles, es bastante difícil que puedan ser replicados por otro evaluador. Y en cuanto al problema de la validez, no es posible verificar de manera inequívoca la adecuación de la medida con aquello que se supone debe ser medido, ya que generalmente estos son constructos que no son susceptibles de verificación empírica directa. Todo esto indica que las pruebas proyectivas deben ser usados con precaución y en conjunto con otras medidas de evaluación.

2.1.2.2. - Pruebas de inteligencia: escalas de Weschler.

Las pruebas de Weschler(WIPPSI, WISC y WAIS) pretenden evaluar la inteligencia a través de su expresión conductual; cada una de ellas se divide en dos subescalas; la primera mide habilidades de tipo verbal, en tanto que la segunda evalua las habilidades manuales o de ejecución.

El puntaje bruto obtenido en la prueba se transforma en puntaje estándar, para sumar los subtest verbales, manuales o ambos juntos para determinar un CI verbal, CI manual y/o el CI total. A partir de los puntajes estándar se hacen los análisis cualitativos porque éstos determinan la posición del sujeto con respecto a la norma de su edad. Se toma como criterio de normalidad un puntajes estándar de 10 (de 9 a 11 puntos).

Además de la medición de inteligencia, se pueden extraer otros indicadores de la aplicación de las pruebas de Weschler.

  • La indicación más clara de problemas emocionales en el entrevistado en una disminución en los ítems de aritmética y dígitos, porque son las pruebas más dependientes de atención y concentración.
  • Indicador de una lesión cerebral, estructural o funcional, es la diferencia de más de 15 puntos entre el CI verbal y manual. En el caso de los adultos, la discrepancia entre los 2 CI es más claramente indicador de daño que de disfuncionalidad o inmadurez.

Descripción del informe.

Se empieza la descripción de las funciones partiendo por las que están en mejores condiciones, disminuyendo hasta las peores. Se nombra la función y el nivel de desempeño, sin agregar puntaje ni el nombre del subtest correspondiente.

Se puede agregar la descripción cualitativa de algunos ítems, como el de semejanzas (que identifica análisis concreto, funcional o abstracto, por ejemplo).

  • Resultado cuantitativo.
  • Análisis cuantitativo.
  • Análisis cualitativo.
  • Observaciones del evaluador sobre el desempeño (interrupciones, etc.).
  • Desempeño armónico o disarmónico.
  • Nivel de deterioro (cuando corresponda).
  • Nivel de desempeño en subtest sensibles a la ansiedad.
  • Dispersión intertest.
  • Verbalizaciones significativas del sujeto.
  • Índices de organicidad (cuando haya disfunción patológica).
  • Recomendación de reevaluar (cuando se noten alteraciones agudas).
  • Alternancia de rendimiento en un mismo test (función).

 

2.1.2.3. - Escalas de diagnóstico y personalidad: MMPI

El MMPI es un cuestionario de personalidad de 566 ítems, de formato papel y lápiz, creado a comienzos de la década de los 40 y se elaboró por puntos seleccionados bajo un enfoque empírico. En 1989 se realizó una versión revisada, el MMPI 2, el cual incluye la revisión del formulario de respuestas, añade varias escalas de comprobación y de personalidad y recoge datos normativos actuales.

El MMPI comprende 10 escalas clínicas(hipocondría, depresión, histeria, desviación psicopática, masculinidad/femineidad, paranoia, psicastenia, esquizofrenia, hipomania, introversión social), 4 escalas auxiliares (ansiedad, represión, fortaleza del yo y alcoholismo) y tres escalas de validez (mentira, infrecuencia y supresora o de ajuste).

Entre las ventajas del MMPI se encuentra el hecho de que al ser ocupado a gran escala, se cuenta con un gran conjunto de investigaciones que señalan las correlaciones del MMPI con distintos tipos de entes clínicos, lo que proporciona información descriptiva, predictiva, diagnóstica y pronóstica. Otra ventaja radica en su naturaleza ateórica, lo que incrementa su utilidad.

Entre las desventajas, se señala que los datos normativos de la prueba son anticuados. En relación al MMPI-2, la cohorte normativa presentaría un nivel educativo elevado y no es posible comparar los resultados de esta prueba con el MMPI-1, ya que existen diferencias significativas en la forma de la escala y el tipo de código, por lo que la información acumulada en el MMPI no puede ser extrapolada directamente al MMPI-2. Con respecto al aspecto práctico, las pruebas son extensas y las personas que las responden indican que es mucho el tiempo requerido para completarlas, por lo que se han realizado versiones abreviadas, en las cuales se encuentran comprometidas la confiabilidad y la validez. (Kaplan y Sadock, 1997).

 

2.1.2.4.- Pruebas de organicidad.
2.1.2.4.1.- Test de Bender:

Originalmente fue pensado como un test de personalidad por la teoría Gestalt. Sin embargo, analizando las reproducciones que hacía el sujeto en relación a diagnósticos clínicos se hizo evidente que el test era útil para detectar organicidad (daño cerebral). También hay una escala de valoración emocional que puntúa otros ítems, donde se puede detectar perturbación o problemas a nivel afectivo; no dice la naturaleza de la alteración sino su existencia o inexistencia. Junto a esto, se puede determinar la posible presencia de trastornos psiquiátricos.

 

2.1.2.4.2.- Escalas de Weschler.

Como se ha señalado anteriormente, las escalas de Weschler pueden detectar organicidad, en tanto se presentan diferencias muy grandes de rendimiento (mayores a 15 puntos) entre las dos subescalas. También se sospecha daño orgánico en caso de alternancia de rendimiento, o sea, cuando el individuo responde de manera alterna a ítems de creciente dificultad.

El CI de la subescala de rendimiento o manual es un predictor casi tan confiable de presencia de lesión cerebral como el de la escala completa. El deterioro desproporcionado de la escala verbal se asocia, sobretodo, con lesiones en el hemisferio izquierdo. Los pacientes con lesión en el hemisferio derecho presentan un deterioro específico en la escala manual con lenguaje casi intacto y CI verbal normal, con dificultades de la guía visual del movimiento.

Las lesiones del lóbulo parietal de cada hemisferio pueden comprometer la capacidad visoespacial. La hemiparesia leve derecha puede reducir la velocidad de codificación y, por lo tanto, el CI de rendimiento, en un paciente con enfermedad del hemisferio izquierdo (Kaplan y Sadock, 1997).

2.1.3.- Crítica al modelo diagnóstico-evaluativo

2.1.3.1.- Crítica a la aplicación del modelo médico a la conducta anormal.

Según Gergen (1994), en la conceptualización del trastorno mental por parte del modelo médico ha primado una conceptualización de tipo pictórica del trastorno mental, en el cual se haría referencia a la acción de crear términos que reflejarían condiciones existentes en la mente. De este modo, la gente expresa enunciados sobre su estado mental y el terapeuta intenta, a través de las palabras del paciente, "ingresar" en su mundo. Existen variadas críticas acerca de este enfoque pictórico del lenguaje en la ciencia, ya que los términos constituirían meras construcciones; en la psicología, el problema es aún mayor, ya que no existe la posibilidad de crear referentes concretos visibles que unifiquen criterios. El lenguaje pictórico de los estados mentales, entonces, tendría un carácter reificativo, es decir, trata como real aquello de lo que habla el lenguaje, sin cuestionarse la certeza de ese conocimiento; esto no significa que en la mente del individuo no ocurran diversos procesos al realizar una acción, pero no nos es posible asegurar con certeza que un individuo "posea" un determinado estado mental al realizar determinadas conductas.

De acuerdo a estos planteamientos, el modelo médico parte de supuestos no comprobados, por lo que su utilización en la resolución de problemas psicológicos puede traer efectos negativos, ya que por una parte, considerara a la conducta como determinada de modo unilateral y exhaustivo por variables de tipo biológico - en el enfoque tradicional - o por variables psicológicas y sociales - en los modelos psicosociales -, no considerando planteamientos teóricos alternativos que consideran a la conducta humana como parte integrante de un sistema complejo, con características como la causalidad circular y la equifinalidad, que imposibilitan la atribución de un comportamiento a una o más causas determinadas, ya que las supuestas "causas" y "efectos" se determinan mutuamente en pautas más complejas de interrelación, donde las causalidades definidas por un observador determinado son meras puntuaciones dentro de una pauta mayor que tiene como función mantener la homeostasis de un sistema más complejo (Escobar y Cova, 1997; Keeny, 1987). Por otra parte, desde una perspectiva conductual, la condición de anormalidad o normalidad no son cualitativamente distintas, sino que reflejan juicios de las personas basados en una multitud de criterios; además, los procesos que llevarían a la génesis, manutención y desarrollo de la conducta normal como de la anormal serían los mismos - procesos de aprendizaje, diversos factores psicobiosociológicos. (Martínez, 1998b)

Razones que explican la utilización del modelo médico para el enfrentamiento de la conducta anormal

Según Martínez (1998b), entre los factores que permiten entender la aplicación del modelo médico a los problemas de conducta anormal, encontramos:

  1. La fuerza histórica de la autoridad de la medicina: porque su ejercicio es capaz de aliviar el sufrimiento y mantener la vida.
  2. Redefinición como enfermedad de las "posesiones demoníacas" y el consiguiente beneplácito por parte de la sociedad: se dio origen a un trato más benigno para los pacientes de hospitales psiquiátricos, induciendo una visión naturalista a la investigación.
  3. Correlación entre determinadas disfunciones cerebrales y patrones anormales de comportamiento: lo que indujo a sostener una causalidad directa entre ellas.
  4. Desarrollo de los psicofármacos a partir de los '50, que demostraron ser eficaces para reducir transitoriamente las manifestaciones psicológicas perturbadas.
  5. Relativa ignorancia psiquiátrica de los avances en el conocimiento psicológico.
2.1.3.2.- Consecuencias de la aplicación del modelo médico a la conducta anormal.

Gergen(1994) señala 3 consecuencias negativas sobre la sociedad y el individuo de esta forma pictórica de describir los trastornos mentales:

  • Jerarquía social: El vocabulario del déficit mental tiene como base diversas suposiciones sobre el bien cultural, sobre el ideal de personalidad y las ideologías políticas asociadas, siendo, de este modo, pautas de evaluación de las personas. Los términos del déficit mental degradan a los sujetos que son calificados, creando jerarquías sociales entre los "individuos poco ideales" y los "normales".
  • Erosión Social: Los términos del déficit mental se insertan dentro de la realidad médica y, por lo tanto, participan de los conceptos de enfermedad, diagnóstico profesional y tratamiento; los individuos son eliminados de su contexto social para entrar en un proceso de "realineación profesional", lo que rompe los lazos del individuo con su comunidad. La comunicación que se establece con el terapeuta, en términos generales autorreferente, va en desmedro de la comunicación que debería existir entre los individuos en su vida habitual.
  • Autodebilitamiento: Los términos del déficit mental caracterizan al individuo en su totalidad; no se limitan a una circunstancia particular, sino que afectarían a todas las conductas que el sujeto realiza; así, todas las acciones futuras del individuo, tras el diagnóstico, son vistas en función de su potencialidad problemática o en lo disminuida que puedan estar por el trastorno mental. Junto a esto, los existencialistas reclaman que el vocabulario del déficit le quita a las personas la posibilidad de sentirse actores de sus vidas, ya que las enfermedades mentales le impedirían llevar el control de sus pensamientos y acciones, las cuales sólo podrían ser guiadas adecuadamente por profesionales. Además, el vocabulario del déficit desvía la búsqueda de las causas de los trastornos de su contexto cultural, salvando a la sociedad de su responsabilidad.

 

2.2.- Enfoque terapéutico integrado.

Como respuesta al modelo médico de enfrentamiento a la conducta anormal, han surgido variadas respuestas desde muchos campos del conocimiento, y especialmente desde la psicología. En la presente sección se presentarán distintos modelos que pretenden dar respuesta al como se desarrollan las enfermedades mentales y como enfrentarlas, desde distintos niveles de acercamiento que disienten o complementan en modelo médico. En primer lugar, se presentará en modelo biopsicosocial multifactorial de EVAC, el cual da cuenta de cómo se desarrollan y mantienen las enfermedades mentales; en segundo lugar, se presenta una breve descripción del modelo de evaluación conductual, el cual constituye un complemento muy valioso al enfoque diagnóstico psiquiátrico al entregar datos pertinentes a la etiología y al tratamiento de los factores psicosociales del trastorno mental. Finalmente, se entregará una breve reseña acerca de las características y objetivos de la psicología comunitaria, la respuesta frente al descontento hacia los modelos individuales de tratamiento hacia las enfermedades mentales, y en relación al punto anterior, se presentará una forma alternativa de relación en el contexto de los servicios hospitalarios de salud mental

 

2.2.1.- Enfoque alternativos de evaluación y tratamiento de la conducta anormal

2.2.1.1.- El modelo EVAC o de estrés-vulnerabilidad-afrontamiento-competencia (Liberman, 1993)

Introducción.

Como un modo de explicar la extrema variedad inter e intraindividual en la evolución de los trastornos mentales crónicos, se ha postulado un modelo biopsicosocial que toma en cuenta tanto las variables que influyen en el inicio, evolución y desenlace de los síntomas y en el comportamiento social del individuo de conducta anormal; éstas comprenden las variables que favorecen la aparición de trastornos mentales, sean de orden interno - factores de vulnerabilidad - o externo - situaciones de estrés así como los factores que protegen al individuo; si bien este enfoque se ha utilizado para explicar el desarrollo de la esquizofrenia, parece ser un buen punto de referencia para comprender otros trastornos, tales como la depresión por ejemplo.

Las variables involucradas en el modo son conceptualizadas en los siguientes términos por Liberman(1993):

"Los factores de vulnerabilidad para producir trastornos mentales graves son anormalidades patológicas, relativamente resistentes de los individuos, presentes antes, durante y tras los episodios sintomáticos. Las variables protectoras o moderadoras son factores ambientales y personales que determinan cuándo un determinado nivel de vulnerabilidad al trastorno mental conduce a una sintomatología manifiesta bajo un determinado nivel de estrés. Los estereros son acontecimientos ambientales o transitorios que exigen del individuo cambios para adaptarse y que cuestionan su capacidad de afrontamiento y competencia habituales" (Liberman, 1982, en Liberman, 1993, p.31).

Sintomatología, conducta: un producto de los factores agresores y de protección.

De acuerdo al modelo EVAC, el individuo que presenta una afección psiquiátrica no puede considerársele un "enfermo", sino una persona con una predisposición a sufrir determinada sintomatología, la cual será elicitada por la presencia de acontecimientos vitales estresantes o por la tensión presente en la familia o en trabajo, en tanto estos sobrepasen las capacidades de afrontamiento del individuo o de su medio social:

"Para los modelos biologicistas o psicosociales, los períodos de salud del sujeto vulnerable son considerados como respiros temporales en una vida de continuos trastornos. Para el modelo de la vulnerabilidad, los episodios de trastorno no son sino interrupciones temporales de una vida esencialmente sana".(Lemos, n.d., p.244)

. De este modo, es importante considerar que para evitar la recidiva en cualquier tipo de trastorno es importante que se encuentren presenten los factores de protección del individuo, siendo los más importantes la capacidad de afrontamiento y competencia de los individuos, las familias, los sistemas de apoyo naturales y el tratamiento profesional; este último incluye , por un lado, la mantención de una medicación que controle los factores biológicos de vulnerabilidad, y por otro, los programas de rehabilitación conductual que incluyen el aprendizaje de habilidades sociales y laborales.

La rehabilitación psicológica de acuerdo al modelo EVAC

En primer lugar, el modelo EVAC alienta a diseñar intervenciones farmacológicas que modifiquen el efecto de los factores de vulnerabilidad psicobiológicos, elevando el umbral en el que lo estresores ambientales precipitan la sintomatología; no obstante, la modulación de la vulnerabilidad biológica no resuelve del todo la susceptibilidad a las recaídas cuando la persona se enfrenta a estresores importantes, cuando se pierde el apoyo social o se ve sobrepasada la capacidad de resolver sus problemas. Tomando en cuenta esto, resulta fundamental el papel de las "intervenciones psicosociales específicas para desarrollar habilidades de afrontamiento personales y familiares y competencia interpersonal a modo de factores de protección"(Liberman, 1993, p.31)

El afrontamiento da cuenta de los "modos tanto intrapsíquicos como comportamentales mediante los que las personas manejan las demandas de un suceso estresante y las emociones asociadas a éste" (Pez, 1985, p.396) , los cuales evitan la aparición de una recaída. Entre los factores que intervienen en las conductas de afrontamiento encontramos la percepción de autoeficacia, las habilidades sociales y de autonomía del individuo, la presencia de una red de apoyo que le brinde las herramientas necesarias a éste para lograr sus objetivos y la presencia de habilidades y capacidades suficientes para enfrentarse a los desafíos y cambios del ambiente. Todos estos factores influyen en la competencia real del individuo, o sea, la capacidad que tendrá el sujeto para satisfacer sus propias necesidades.

 

2.2.1.2.- La Evaluación conductual

Según Liberman (1993), un adecuado diagnóstico de acuerdo al modelo psiquiátrico (una correcta clasificación dentro de las categorías del DSM-IV), permitiría una "adecuada prescripción farmacológica, la decisión sobre tratamientos y ubicación del paciente, la elección de actividades terapéuticas y mejorar las estrategias del paciente para afrontar y dominar la psicopatología"(p.63).

Mientras que la evaluación sintomatológica parece ser la adecuada para determinar el tipo de farmacología a utilizar (recordemos que el modelo médico es el adecuado para estudiar y tratar los asuntos biológicos), el enfoque adecuado para analizar y tratar los problemas psicosociales parece ser el de tipo conductual; de acuerdo al enfoque EVAC, es necesario comprender los dos aspectos.

La evaluación conductual es el método que permite determinar los déficits, excesos y logros conductuales del paciente que facilitan o perjudican las actividades del paciente. Se parte con una operacionalización de los problemas del paciente en términos conductuales concretos y específicos, con la finalidad de lograr una adecuada observación y cuantificación de éstos, con el propósito de establecer objetivos (también conductuales), claros, precisos y susceptibles de medición; junto a esto, se realiza un análisis funcional de la conducta, de modo tal de establecer cuales son los antecedentes y consecuentes de la conducta problema, de modo tal que permita determinar cual será el tipo de tratamiento (programa de reforzamiento, modelado, moldeado, etc.) a utilizar (Escobar y Cova, 1997; Martínez, 1998a; Liberman, 1993)

2.2.1.3.- La Psicología Comunitaria

La Psicología Comunitaria concibe al individuo como un participante en varios sistemas sociales y encauzar la intervención hacia la modificación de esos aspectos de un sistema que favorecen la adquisición de reacciones anormales.

Una de las fuerzas impulsoras del movimiento de intervención a nivel comunitario a fines de los 50 e inicios de los 60 fue la decepción que produjo en algunos círculos la aplicación de los métodos tradicionales al tratamiento de psicopatías. Todos ellos insistían en la necesidad del tratamiento individual y de confinar a los pacientes en instituciones psiquiátricas; los partidarios de la psicología comunitaria se inclinan por la prevención de la conducta anormal, o por lo menos, su detección temprana y la aplicación del tratamiento antes que empeore el paciente. Lo importante es evitar la génesis de la psicopatología en base al cambio de los sistemas sociales que la propician(Martin, 1985).

De este modo, la Psicología comunitaria es un enfoque de la salud mental que toma en cuenta la influencia de los factores ambientales y fomenta el uso de recursos y agencias comunitarios para eliminar la condición que producen problemas psicológicos. Para muchos su enfoque y énfasis ecológico en la competencia y en la prevención representan una desviación drástica de las practicas de la psicología clínica. Esta diferencia es evidente en especial en los siguientes áreas importantes de concentración:

  • Enfoque ecológico social: la psicología comunitaria se enfocan la ecología humana, la interacción entre los seres humanos y sus ambientes.
  • "hacer igual que estudiar": se enfatiza la teoría y la práctica. Los psicólogos comunitarios intentan no sólo comprender y estudiar los factores contextuales, sino además aplicar la investigación a problemas y cuestionar la vida real.
  • Enfasis en las ventajas y competencias psicológicas: la psicología comunitaria busca fomentar las competencias y aumentar el potencial de afrontamiento de las personas que pueden exhibir o no los trastornos mentales.
  • Actividades de prevención: los psicólogos comunitarios abogan por programas que previenen el desarrollo de casos nuevos de problemas emocionales y conductuales.

La Psicología comunitaria ha evolucionado sobre todo en respuesta a una insatisfacción creciente con los enfoque tradicionales de la Salud mental. El interés en la psicología comunitaria creció en parte debido que los psicólogos se preocuparon más por el papel de las fuerzas ambientales que por la dinámica de la psique del individuo; de este modo, se sugiere que la adaptación de una persona depende de la naturaleza y el grado de estresantes ambientales, de las competencias y habilidades del individuo y de los tipos de recursos disponibles en la comunidad para ayudar a las personas a enfrentar el estrés (Sue et al., 1996)

Desigualdades en la distribución de servicios:

Un factor importante que influyó en el desarrollo del movimiento de la psicología comunitaria fue la calidad discriminativa o carente de respuestas de los servicios de salud mental disponibles para miembros de grupos minoritarios y pobres. Varios estudios han indicado las dificultades para establecer confianza, compenetración y una relación de trabajo entre pacientes y terapeutas que difieren en raza, clase socioeconómica y estilo de vida. Los terapeutas que difieren de los pacientes en estas características pueden ser insensibles a las necesidades de su clientes o pueden fallar en considerar de manera adecuada la influencia del ambiente social en el que viven sus pacientes.

La búsqueda de enfoques alternativos para la atención de la Salud Mental ha sido estimulado por la falta de profesional suficiente para satisfacer la necesidad del tratamiento especializado, por inconformidad con el enfoque actual, por los costos elevados y la ineficacia de la, hospitalización y por la desigualdades en la distribución de los servicios de Salud Mental.

Los programas basados en la comunidad son muy diversos. Sin embargo, varias características son muy particulares del enfoque comunitario de la psicología. Éstas incluyen establecer un sistema de centro de salud mental comunitarios, enfatizar la prevención, el entrenamiento de los paraprofesionales, volverse activos social y políticamente y hace un uso creciente de los apoyos profesionales.(Sue et al, 1996)

2.2.1.4.- La función del psicólogo en el ambiente de la salud mental.

En vez de tratar de suprimir completamente la hospitalización, como sugieren algunos partidarios de la psicología comunitaria, otros proponen cambios radicales en el ambiente hospitalario para que sea más terapéutico; es aquí, donde el psicólogo puede cumplir una importante función.

Maxwell Jones (1953) fue uno de los primeros psiquiatras que puso en práctica estas ideas. El implementó una "unidad de rehabilitación social", en el Belmont Hospital, cerca de Londres, y a su método lo llamó comunidad terapéutica. Se planteaba que los pacientes participaran activamente en su tratamiento y en el de otros, así como en varios aspectos de las actividades diarias del hospital, lo cual contrastaba notablemente con su papel pasivo habitual. También se modificaron las funciones del personal. En las reuniones de la comunidad, lo médicos, enfermeras y psicoterapeutas debían abandonar su papel normal e interactuar entre sí y con los pacientes en forma espontánea. La finalidad global de esta terapia ambiental era crear una atmósfera de aceptación y respeto que ayudará a reinstaurar la autoestima del paciente, a menudo destruida, y convencerlo de que debía intervenir en el proceso de su rehabilitación.

Este programa tiene la necesidad de ser aplicado por personal especializado, que sepa tratar al paciente como un ser humano y no como un enfermo, además de persuadirlo de asumir cada vez mayores responsabilidades en torno a su vida y a su rehabilitación. El psicoterapeuta debe enseñar habilidades específicas al paciente, como al resto de la comunidad terapéutica, para que el fin de crear un ambiente hospitalario más terapéutico se logre.

2.2.2.-Vías de intervención del psicólogo en los problemas psiquiátricos.

De acuerdo a lo planteado en la sección anterior, se pueden concluir que no es posible el enfrentamiento de los problemas psiquiátricos mediante intervenciones aisladas, sino que se hace necesario un enfoque biopsicosocial que involucre la mayor cantidad de factores que puedan afectar al individuo, junto a "una orientación de prevención y cambio social [...]; es decir, de transformación de los factores sociales causantes del deterioro emocional" (Páez, 1985, p.402).

Es aquí donde el psicólogo puede cumplir un rol fundamental. Si bien el control de las variables biológicas le compete al psiquiatra, todo lo relacionado con la enseñanza de habilidades sociales, cambio conductual, cambio social y esfuerzos comunitarios son aspectos que están directamente relacionados con la formación del psicólogo como tal. Como ejemplo de posibles vías de intervención, se detallarán dos importantes tareas que le competen al psicólogo en la atención de sujetos con problemas psiquiátricos: el adiestramiento en habilidades sociales y la intervención en la familia.

 

2.2.2.1.- Adiestramiento en habilidades sociales.

Los sujetos que sufren de afecciones psiquiátricas, especialmente los esquizofrénicos, presentan generalmente deficiencias en habilidades sociales, lo cual les produce dificultades tanto para lograr la satisfacción de sus necesidades materiales como de filiación. Así, "a menudo son explotados, apartados o simplemente ignorados en la actividad de la vida diaria. En ocasiones, frustrados por su incapacidad para satisfacer sus necesidades, actúan agresivamente y hostilmente"(Liberman, 1993, p.131). En gran parte, los problemas de los pacientes con problemas mentales radica en la dificultad que tienen para expresar sus deseos y sentimientos, lo que les impide relacionarse de manera adecuada con las personas de su ambiente, disminuyendo su calidad de vida. Se ha relacionado esta deficiencia en el ámbito de las habilidades sociales con un aumento en el pronóstico de recaídas y la presencia de estas habilidades como un indicador protector para la aparición de la esquizofrenia y como un factor reductor de las tensiones familiares y de los índices de rehospitalización.

Las habilidades sociales se conceptualizan como aquellas capacidades - comunicación verbal y no verbal, sentimientos, percepciones y actitudes ante el contacto interpersonal - que posibilitan resultados satisfactorios en la interacción interpersonal; entre las habilidades sociales principales encontramos la percepción social adecuada, el procesamiento cognitivo adecuado de la situación social para una buena selección de alternativas y la adecuada ejecución conductual de la alternativa elegida. Las habilidades sociales pueden ser consideradas como uno más de los procesos de afrontamiento al trastorno mental; de acuerdo a las teorías del aprendizaje, el aprendizaje de comportamientos prosociales reforzantes desplaza la conducta desadaptativa ( o en lenguaje médico, sintomática).

La adecuada implementación de un programa de habilidades sociales incluye los siguientes pasos (Liberman, 1993):

  • Definición del problema de una manera operacional.
  • Inventario de las capacidades del paciente en el aspecto social.
  • Establecimiento de una alianza terapéutica reforzante
  • Establecimiento de objetivos concretos y específicos, evitando la discusión excesiva sobre los problemas del paciente
  • Ensayo conductual de las habilidades a adquirir.
  • Reforzamiento positivo de las conductas objetivo
  • Moldeamiento, o constitución de secuencias de aprendizajes sencillos para el logro final de un aprendizaje complejo
  • Modelamiento, o demostración in vivo de la conducta deseada.
2.2.2.2.- Intervención en la familia

Desde hace tiempo se ha señalado la importancia de la familia en relación a los trastornos psiquiátricos. En una primera instancia, se señaló la posible etiología genética de la conducta esquizofrénica; más tarde, teorías como la del "doble vínculo" ya no señalan una causalidad de tipo biológico, sino psicosocial en el surgimiento de la esquizofrenia. La teoría de sistemas ha generado una abundante literatura sobre las estructuras y pautas de comportamiento características de las familias que presentan miembros ya sea anoréxicos(Díaz, Gayó y otros, 1999) , como esquizofrénicos (Martí-Tusquets, 1982).

Desde un enfoque centrado en la integración de acciones a nivel terapéutico entre psiquiatras y psicólogos, el modelo conductual de intervención familiar parece ser el más adecuado. Esta visión considera que la responsabilidad primaria de la atención de las personas con trastornos conductuales recae generalmente en la familia, la cual debe prepararse a través del aprendizaje de las características del trastorno del individuo afectado y el adiestramiento en habilidades específicas para afrontar a largo plazo la afección; además, debe brindarse apoyo a las familias afectadas por el estrés y tensión.

Los objetivos centrales del tratamiento de familia son :

  • Reducir la tensión del paciente y de su familia entregando información clara sobre el trastorno: es importante que el terapeuta presente de manera clara y adecuada a la familia las características de la afección, de manera tal de disminuir el nivel de autoculpabilización, confusión e indefensión de la familia, de manera tal de que se formulen objetivos más realistas con el paciente.
  • Enseñar habilidades de resolución de problemas: como se ha señalado anteriormente, uno de los factores que predispone al paciente a las recaídas es la presencia de factores estresantes que no pueden ser superados con los recursos disponibles. De ahí que es necesario preparar a las familias y al individuo en habilidades que permitan un afrontamiento adecuado a los problemas, reduciendo la carga de estrés sobre cada miembro del grupo y especialmente sobre el paciente.

2.2.3.-Rol del psiquiatra y el psicólogo en distintos trastornos conductuales.

2.2.3.1- Depresión

La depresión es un trastorno afectivo que se caracteriza por tristeza intensa, sentimientos de inutilidad y aislamiento de los demás. También se presentan síntomas cognitivos como pesimismo profundo acerca del futuro, desinterés, disminución de la energía, pérdida de la motivación y pensamientos suicidas.

Tratamiento

Rol del psiquiatra: Este se encarga fundamentalmente de tratamientos biomédicos que alteran el estado físico o bioquímico del paciente, lo que incluye la medicación y terapia electroconvulsiva.

La medicación incluye la utilización de dos tipos de fármacos: los antidepresivos tricíclicos, que son considerados como los más efectivos, y los inhibidores de la monoaminoxidasa (MAO). Aunque los inhibidores de la MAO son recetados en la actualidad para pacientes deprimidos que no han respondido bien al tratamiento con tricíclicos, tienen muchos efectos secundarios que incluyen insomnio, irritabilidad, mareos, estreñimiento e impotencia; el más grave es la incompatibilidad con la tiramina del queso, la cual se encuentra en productos consumidos diariamente, por lo que si alguien está utilizando algunos de estos fármacos debe restringir el consumo de tiramina, pues de no hacerlo, desencadena una reacción que comienza con un aumento de la presión sanguínea, vómitos y contracción muscular y puede dar como resultado una hemorragia intracraneal seguida por la muerte.

La terapia electroconvulsiva se reserva para pacientes con depresión grave que no han respondido bien a los fármacos. El procedimiento consiste en aplicar un voltaje eléctrico moderado al cerebro durante hasta medio segundo. La respuesta del paciente es una convulsión (ataque) que dura unos 30 segundos seguidos por una coma de 5 a 30 minutos. Los pacientes con depresión más grave muestran al menos una mejoría temporal, sin embargo los efectos secundarios incluyen dolores de cabeza, confusión y pérdida de la memoria. Esta técnica es controvertida y muchos han sugerido que sea prohibida.

Rol del psicólogo: Debido a que el uso de medicación antidepresiva implica una cantidad de desventajas, se ha procurado un enfoque psicoterapéutico para la depresión. Una variedad de formas psicológicas de tratamiento han sido usadas (psicoanálisis, terapias interpersonales y familiares), todas éstas presentando algo de éxito. La terapia más prometedora resulta ser la cognitivo conductual.

Terapia cognoscitiva conductual: Como su nombre implica, la terapia cognoscitiva conductual combina estrategias cognoscitivas y conductuales. El componente cognoscitivo implica enseñar al paciente: 1) a identificar pensamientos (cogniciones) autocríticos negativos que ocurren de manera automática, 2) a notar la conexión entre los pensamientos negativos y la depresión resultante, 3) a examinar con cuidado cada pensamiento negativo y decidir si puede ser apoyado y 4) a intentar reemplazar los pensamientos negativos distorsionados con interpretaciones realistas de cada situación (Sue, D. et al. 1996). La terapia cognitiva conductual parece muy promisoria como un tratamiento plausible para la depresión; incluso, esta terapia puede reducir el riesgo de episodios de depresión que ocurren después del tratamiento.

Otra técnica dentro de este mismo enfoque consiste en utilizar el autorrefuerzo en el tratamiento de la depresión. Se ha observado que el deprimido suele asignarse tasas bajas de autopremio y altos índices de autocastigo en comparación con los no deprimidos. En base a esto se ideó un sistema de adiestramiento destinado a invertir esas tendencias de autorrefuerzo. En primer lugar enseñaron a los individuos a asistir a acontecimientos más positivos o agradables, a fijarse metas realistas y graduales de cambio conductual, a sumistrarse abundantes premios dependientes de la realización de pequeños pasos hacia su meta.

Los pacientes deprimidos tratados con terapia cognoscitiva tienen menor probabilidad de desarrollar síntomas subsecuentes de depresión en comparación con aquéllos tratados farmacológicamente. Los cambios cognoscitivos en los estilos explicativos y las atribuciones entre los pacientes en terapia cognoscitiva pueden ayudar a prevenir los síntomas depresivos. Se han hecho algunos intentos para combinar la terapia cognoscitiva y la cognitivo conductual con la medicación antidepresiva. Los primeros hallazgos en dicho tratamiento han sido positivos. La investigación posterior ha cuestionado si la combinación es superior al uso de sólo una (terapia cognoscitiva o medicación antidepresiva). Una revisión reciente en la investigación ha indicado que la terapia cognoscitiva es tan efectiva como usar medicación y que usar ambas no es superior a usar cualquier forma de tratamiento para pacientes con depresión aguda.

2.2.3.2.- Esquizofrenia-psicosis

La esquizofrenia es un tipo de trastorno clasificado según el DSM IV dentro de los trastornos psicóticos. Los síntomas de la esquizofrenia implican delirios, alucinaciones, trastornos del pensamiento y conducta extraña. Estos son descritos a menudo como síntomas positivos, o que están presentes durante la fase activa del trastorno y tienden a desaparecer con el tratamiento. Los síntomas negativos son asociados con funcionamiento social premórbido inferior y un pronóstico peor. Estos incluyen afecto abatido, pobreza de lenguaje, anhedonia y apatía (Sue et al, 1996).

Tratamiento

Rol del psiquiatra: Aparte del proceso evaluativo y diagnóstico de la esquizofrenia, el psiquiatra se encarga fundamentalmente de tratar con la base biológica de la esquizofrenia, por medio de la medicación antipsicótica o neurolépticos. Actualmente el fármaco de mayor uso es la Clozapina, pareciendo ser que posee menos efectos secundarios que otros medicamentos.

Las medicaciones antipsicóticas están lejos de ser perfectas y pueden producir diversos efectos secundarios desagradables en extremo que semejan condiciones neurológicas. La mayor parte ofrece poco alivio para los síntomas negativos tales como retraimiento social, apatía e higiene personal deteriorada. Y muchos esquizofrénicos no se benefician en absoluto de la medicación antipsicótica. A pesar que la clozapina tiene menos efectos secundarios, podría aparecer la agranulocitosis, la cual implica lesiones de las membranas mucosas o del sistema gastrointestinal, lo que es potencialmente fatal. Además los clínicos a menudo no se percatan de posibles reacciones a los fármacos como por ejemplo, intranquilidad motora , terror extremo e incluso intentos suicidas compulsivos.

Rol del psicólogo: La mayoría de los clínicos en la actualidad están de acuerdo en que el tratamiento más benéfico para la esquizofrenia es alguna combinación de medicación antipsicótica y terapia, es aquí donde interviene el psicólogo.

Terapia cognitivo conductual: Debido que los esquizofrénicos carecen de manera típica de habilidades sociales, casi siempre se incluye un programa de entrenamiento para contrarrestar esta carencia como parte de la terapia conductual. La terapia enfatiza las habilidades de comunicación y el entrenamiento de la asertividad. El paciente es colocado de manera repetitiva en situaciones sociales que tiende a evitar. Esto disminuye la ansiedad del paciente al punto de que las buscará en lugar de evitarlas. Esta es una contribución fundamental debido a que el retraimiento social es un síntoma esquizofrénico que no es tocada por la medicación psicótica. (Martin, B. 1985). Este tipo de terapia también ha sido usada para reducir el impacto de delirios , alucinaciones y otros trastornos del pensamiento, por medio de explicaciones desestigmatizantes de sus síntomas y entrenamiento para cuestionar los síntomas psicóticos. Se les explica que el estrés a menudo produce reacciones comunes como ideas de referencia, paranoides e interpretaciones equivocadas de los eventos. Los pacientes son enseñados a analizar sus síntomas, llegando a concluir que sus creencias no son realistas.

Otro tipo de intervención es la Terapia psicológica integrada (TPI). Este programa identifica las deficiencias cognoscitivas específicas mostradas por los esquizofrénicos e implica: a) Diferenciación cognoscitiva, en la cual los pacientes son enseñados a discriminar categorías de estímulos al participar en tareas perceptivas, aprendiendo a formar conceptos y a recuperar información apropiada. b) Percepción Social, aquí los pacientes aprenden a reconocer de manera apropiada y a responder a las claves sociales. c) Comunicación Verbal, se ayudan a los pacientes aprender a concebir y evaluar las declaraciones verbales. d) Habilidades Sociales e Intervenciones Interpersonales.

Apoyo Familiar: Ya que la mayoría de los pacientes recuperados regresan a vivir con sus familias, las nuevas intervenciones psicológicas se han enfocado de tratar de mejorar la interacción entre el paciente y los miembros de la familia, evitando así posibles recaídas. Esto implica difundir información acerca del trastorno entre las familias e esquizofrénicos y enseñar a éstas y al esquizofrénico cómo modificar sus patrones de comunicación. Para esto se identifican las interacciones estresantes y se realiza un entrenamiento en métodos de comunicación alternativos. Se enfatiza habilidades específicas, tales como escuchar, hacer peticiones claras, enfocar el reforzamiento positivo y reducir las críticas. (Sue, D. 1996)

 

3. - La labor del psicólogo en Chile

3.1. - Antecedentes.

Las enfermedades mentales, tanto en Chile como en el mundo, han experimentado un progresivo aumento en importancia. En Chile, la mortalidad y discapacidad debida a enfermedades mentales es responsable ya de alrededor del 15% de los años de vida que se pierden por causa de la enfermedad. Afortunadamente, estudios sistemáticos acerca de los tratamientos actualmente disponibles para las distintas enfermedades mentales demuestran que su efectividad en cuanto a disminuir la intensidad y duración de la discapacidad, el número de atenciones de salud en general en las personas afectadas y la mortalidad por todas las causas y suicidio tienen un impacto mucho mayor que el costo del tratamiento mismo. Junto a esto, el costo del tratamiento de una enfermedad mental que permite disminuir la pérdida de años de vida saludable es mucho menor que el costo de un programa de Tratamiento por cáncer o un by-pass coronario para conseguir esa misma disminución.

En las políticas de Salud Mental vigentes desde 1993 se definieron como áreas relevantes el Abuso de Alcohol, la Salud Mental de Niños y Adolescentes y los Discapacitados de Causa Psíquica; y se incluyeron estrategias innovadoras promovidas internacionalmente, como la Salud Mental en Atención Primaria, y especialmente, temas emergentes como la

Violencia y el Consumo de Drogas Ilícitas. La implementación del Plan ha sido progresiva y el desarrollo en las distintas áreas se ha dado de manera desigual, de modo tal que no se ha logrado un aumento suficiente de la cobertura, calidad y oportunidad de las atenciones como para que sea valorado por las personas ni para mejorar el nivel de salud mental de la población beneficiaria.

 

3.2. - Importancia de la psicoterapia en el tratamiento de las enfermedades mentales.

De acuerdos a los datos recogidos por el Ministerio de Salud (2000), la psicoterapia sería un pilar fundamental en el tratamiento de las enfermedades mentales. De este modo:

  • Las psicoterapias específicas para depresiones (cognitivas, conductuales, interpersonales) pueden ser tan efectivas como los medicamentos en cuadros de mediana o baja severidad, o reforzar el efecto de los medicamentos en cuadros de mayor severidad.
  • Disminución significativa de síntomas de Trastorno de Estrés Post-Traumático con terapia cognitiva conductual
  • Con terapias conductuales y cognitivas se obtienen resultados comparables a los de medicamentos en Trastornos de Pánico y Agorafobia, con efectos sostenidos durante seguimientos de 2 o más años
  • La adición de tratamientos psicosociales específicos a los antipsicóticos reduce la tasa de reingresos a un 25 a 30% en un período de 2 años
  • Existe consenso entre los expertos nacionales e internacionales acerca de la efectividad tanto de las intervenciones psicosociales y el tratamiento farmacológico con psicoestimulantes Trastornos de Hiperactividad y Déficit Atencional, coincidiendo en
  • que ésta es mayor cuando ambos tratamientos se complementan

3.3. - Brecha entre recursos existentes y recursos requeridos.

De acuerdo a los datos del Ministerio de Salud en 1998(2000), la necesidad de psicólogos en atención primaria está cubierta sólo en un 30%, ya que de los 370 psicólogos necesarios, sólo habría en servicio unos 111. Esto es importante, ya que refleja una necesidad importante por parte de la comunidad de psicólogos.

3.4.- Modelo de funcionamiento de los sistemas de Salud Mental en Chile.

Las políticas a seguir en los próximos años, en los distintos niveles de atención con respecto a la atención psicoterapéutica, son las siguientes:

  • En relación a la atención primaria, se estima necesaria la implementación de establecimientos y equipos encargados de promocionar la salud mental y que posean la capacidad de reconocer, tratar y derivar las enfermedades psiquiátricas, que trabajen en coordinación con el resto del equipo de atención de los centros de atención primaria y dentro de los parámetros dictados por un Programa Nacional de Salud Mental y Psiquiatría; se estima necesaria la incorporación de psicólogos a los centros de salud mental y a los consultorios Urbanos.
  • En relación a la atención psiquiátrica, se requiere de acuerdo a estándares basados en el diagnóstico epidemiológico, a las necesidades expresadas localmente por la población, y a sus características socioculturales, como mínimo en lo relacionado a la psicoterapia:
  • Un equipo de psiquiatría ambulatorio por cada 40.000 beneficiarios (niños, adolescentes, adultos y adultos mayores), conformado por psiquiatra, psicólogo, asistente social, enfermera, terapeuta ocupacional, técnico paramédico y monitor. Este equipo recibe los pacientes solo por derivación del médico de atención primaria. De acuerdo a estándar nacional se requiere de 44 horas de psiquiatra y 44 horas de psicólogo por cada 40.000 beneficiarios. Los profesionales que trabajan en estos equipos, debieran, además compartir horas con otros dispositivos de la red de este nivel o del nivel de Subespecialidad.
  • Hogares y residencias protegidas, con componentes flexibles y diversificados según necesidades de las personas con enfermedad mental, tanto para corta estadía (crisis, transición post internación, etc.) como para larga estadía. Recibe los pacientes derivados por el equipo de psiquiatría ambulatorio y del servicio de psiquiatría de corta estadía. De acuerdo a estándar nacional se requiere 1 plaza por cada 2.083 adultos beneficiarios.

    · Programas de rehabilitación social y laboral, y apoyo a organizaciones de autoayuda, agrupaciones de familiares, y comunidades terapéuticas. Las personas son derivadas a los programas de rehabilitación por el equipo de psiquiatría ambulatorio. Para estos programas se requiere de una coordinación multisectorial efectiva.
    · Reuniones clínicas y de Consultoría periódicas de los equipos de psiquiatría ambulatoria con los equipos de Adicciones, Mediana y Larga Estadía, Salud y Violencia, y Psiquiatría Forense, con el fin de mejorar resolutividad de este nivel y evitar referencias innecesarias a sub especialistas.
  • En relación a la atención de sub-especialidades psiquiátricas, la necesidad de psicoterapeutas no es declarada en forma tan específica, aparece como relevante la presencia de psicoterapeutas en las unidades de acción ambulatoria (encargadas de los pacientes con dependencia al alcohol y a las drogas), en los servicios de larga estadía (pacientes que requieren más de 12 meses de hospitalización), en unidades de salud y violencia ambulatorias y en las unidades de problemas emergentes; en estos servicios, el psicólogo, más que actuar de forma directa haciendo terapia, puede ser un aporte en razón del aporte de nuevos puntos de vista para enfrentar los problemas psiquiátricos, especialmente en lo relacionado al enfoque psicosocial necesario para comprender estos trastornos.

 

3.5. - Propuesta de programa nacional de salud mental y la labor del psicólogo dentro de él.

 

3.5.1. -Características generales del programa.

El programa de salud mental involucra un conjunto de contactos secuenciales de la persona y sus familiares o cuidadores con profesionales o técnicos de salud e integra en sus acciones los principales aspectos que influyen en la salud y la enfermedad de la persona y pone a su alcance una serie de actividades efectivas para reforzarlos, modificarlos y/o compensarlos. Así mismo, incorpora actividades dirigidas a grupos organizados que tienen entre sus objetivos la promoción, la prevención en salud mental y la reinserción social de personas con trastornos.

El propósito del programa es constituirse en un instrumento para la programación de recursos destinados a acciones de salud mental en los establecimientos de salud en función de las necesidades de las personas; para lograr una coordinación efectiva entre los equipos de los distintos niveles de atención para el flujo de pacientes y para disponer de sistema de información útil para la evaluación y monitoreo tanto de las acciones como del nivel de salud mental de la población. Se basa en principios, precisa objetivos y estrategias y describe actividades clínicas que se realizan con el o los beneficiarios para el diagnóstico, tratamiento y rehabilitación, así como los contactos, reuniones, talleres y acciones masivas e intersectoriales a desarrollar para la promoción y prevención en salud mental con la población beneficiaria y otros agentes sociales.

 

3.5.2. - Actividades del programa

Los psicólogos, en el nivel de atención primaria (Consultorios, Centros de Salud, Centros de Salud Familiar, consultas de médicos generales, Centros Comunitarios de Salud Mental Familiar), están encargados de las siguientes tareas:

  • Consultas de salud mental: incluye el diagnóstico psicosocial, intervención psicosocial, seguimiento y refuerzo de adhesión a tratamiento y la referencia a atención médica
  • Intervenciones psicosociales grupales: incluye la entrega de apoyo emocional, refuerzo de adhesión al tratamiento, desarrollo de habilidades, motivación de comportamientos de autoayuda y el incentivo para la participación en agrupaciones de familiares
  • Psicoterapia grupal (familias-pacientes), la cual involucra la modificación de factores psicológicos del trastorno mental,
  • Consultoría de salud mental (junto con el resto del equipo de salud), cuyo objetivo es la detección, educación y referencia de personas con problemas de salud mental.

En el nivel de atención secundaria(Equipos de Psiquiatría Ambulatoria, Consultorios de Especialidades, Centros Comunitarios de Salud Mental Familiar, profesionales, equipos y Centros de Atención Psiquiátrica privados, Servicios de Psiquiatría de Hospitales Generales, Servicios de Urgencia Psiquiátrica, Hospitales Psiquiátricos), los psicólogos realizan las siguientes actividades:

  • Consultoría y enlace de salud mental: se realiza con el equipo de salud general y con otros servicios de salud, con el fin de aumentar la capacidad de prevención, detección y resolución en Salud Mental y para lograr la coordinación de referencias.
  • Psicodiagnóstico psicológico: aplicación de pruebas.
  • Consulta psicológica clínica: Incluye la evaluación psicológica y la intervención psicoterapéutica.
  • Psicoterapia individual: Tiene como objetivo la modificación de factores psicológicos del trastorno mental.

4. -Actividad práctica.

La actividad práctica consistió en una entrevista al psicólogo Roberto Sepúlveda, quien desempeña su trabajo en el hospital psiquiátrico de Concepción como especialista en el área de drogodependencia.

Según él, el elemento diferenciador del psicólogo en el sistema de salud tradicional con cualquier otro profesional, consiste en el campo de la psicometría, porque hoy en día "psicoterapia hace cualquiera". Es en esto donde hace algunos años se ha tratado de legislar para que el psicólogo sea el profesional por excelencia quien realice la psicoterapia, ya que el psiquiatra no tiene una formación o si la poseen ésta resulta incompleta, y hay otro grupo que en forma autodidacta utiliza, a parte de la farmacoterapia, el psicoanálisis y enfoque sistémico.

Otro rol que debe desempeñar el psicólogo al estar inserto dentro de un sistema hospitalario es un enfoque biopsicosocial, es decir, debe trabajar en conjunto y en forma coordinada con médicos-psiquiatras, educadores y asistentes sociales. Esto se consigue, desde el punto del trabajo, ejerciendo una dinámica comunicacional al interior del equipo, lo que permite que exista una constante retroalimentación entre los profesionales, entonces el desafío más grande es insertarse dentro de este equipo. Es en esta interacción de profesionales donde el psicólogo desempeña un rol instruccional, en el que otorga capacitación a los otros profesionales que no tienen la formación psicoterapéutica adecuada, para que puedan realizar tares de apoyo.

Además de esto, el psicólogo realiza labores administrativas como coordinador y dirección de proyectos, que son asignadas dentro del ambiente hospitalario. Esto resulta ser algo agobiante para el psicólogo junto con todas las tareas que realiza (terapia individual, grupal, aplicación de test, etc.), considerando los pocos recursos humanos que existen, en comparación con todo el resto del personal de salud (enfermería, médicos, etc.).

Otro rol preponderante es que el psicólogo cumple, es ser un agente de cambio, impulsador de un método de trabajo diferente, brindando espacios de interacción entre las personas, lo que ha dado una movilidad al servicio muy enriquecedor.

Según el psicólogo entrevistado, también es importante en este tipo de servicio público, tener un rol tremendamente cercano a la ética, porque debemos tener presente que se está trabajando con lo que el sistema ha dejado, garantizándole la probidad al paciente que son los que más lo necesitan. El psicólogo debería utilizar estrategias de autocuidado, lo que se logra manteniendo buenas relaciones con sus compañeros de trabajo, siendo uno mismo consciente de las propias dificultades, teniendo autocontrol y teniendo conocimiento del limite de la ayuda que puede procurar cada uno.

En resumen, los roles que tiene el psicólogo dentro del hospital psiquiátrico serían:

1. Rol de integrado a un equipo.

2. Rol de la psicometría.

3. Rol formador y apoyador hacia el equipo.

4. Rol apegado a la ética.

5. Rol que promueva el autocuidado.

Ante la pregunta de qué es lo que hace imprescindible la presencia del psicólogo en el ambiente hospitalario, el entrevistado responde:

Cuando el psicólogo es capaz de confirmar hipótesis diagnóstica, de descubrir el circuito o la dinámica interna o externa que subyace al problema psicológico. Es aquí donde los datos e información que proporciona el psicólogo se hace necesaria, de modo que su carencia se haga notoria y sea imprescindible que este profesional esté incorporado en el equipo multidisciplinario del trabajo hospitalario.

 

5.- Discusión y conclusión

Existe una gran cantidad de actividades posibles de desempeñar por el psicólogo en el campo de las afecciones psiquiátricas; esta variedad implica la no existencia de un límite claro en cuanto a las actividades que puede desempeñar, salvo lo relacionado con la medicación, que es de exclusiva responsabilidad del médico psiquiatra.

Con el paso del tiempo, el reconocimiento de la importancia de un enfoque biopsicosocial en el enfrentamiento de los trastornos mentales ha fomentado una participación más activa de los psicólogos, los cuales tradicionalmente se habían encargado de las personas con afecciones mentales no psicóticas (neurosis) y, en el caso de las personas con trastornos mentales graves, se había limitado su labor a la evaluación psicométrica. En la actualidad, el psicólogo tiene un rol preponderante en todo lo relacionado con la adquisición de habilidades sociales, interpersonal, el apoyo a los familiares de pacientes psiquiátricos y la terapia a nivel individual como grupal de apoyo a la medicación psicofarmacológica.

En un nivel más global, el psicólogo puede constituirse en un factor de cambio social, de acuerdo a los planteamientos de la psicología comunitaria, que establece el énfasis en un enfoque preventivo, buscando la eliminación de las condiciones de los grupos que favorecen la aparición de trastornos mentales y, en el caso específico de las instituciones de salud mental, mejorar las condiciones de vida de los pacientes, a través de la integración activa de éstos en su tratamiento y en la rehabilitación, tanto de tipo psicosocial como laboral.

No existe una base teórica explícita que trate sobre la separación de roles entre psicólogos y psiquiatras y otros profesionales implicados en el ámbito de la salud mental. Esto es fácil de comprender, ya que todos tratan con el mismo asunto, la conducta humana, la cual presenta una multifactorialidad que hace muy difícil establecer separaciones taxativas de responsabilidades con respecto a la evaluación, diagnóstico y tratamiento de las afecciones mentales. El problema radica en que cada profesional sólo puede abarcar una pequeña área del conocimiento suficiente para enfrentarse a la conducta anormal y quien trata de solucionar un problema de esta índole en un rubro que no forma parte de su especialización, no cuenta con las herramientas suficientes, tanto a nivel evaluativo como de acción que le permita obtener resultados óptimos. Se hace necesario una discusión abierta, sin mezquindades, que lleve a los distintos profesionales de la salud mental a asumir una real responsabilidad por los pacientes, de manera tal de no realizar azarosas intervenciones sin una formación específica previa que permita preveer los riesgos de un tratamiento inadecuado.

Un objetivo fundamental a lograr por lo psicólogos, muy relacionado con lo anterior, es lograr el reconocimiento de su labor, lo que implica la sistematización del conocimiento adquirido y su difusión a la comunidad, de manera tal que tanto los profesionales del ámbito de la salud mental como los usuarios tengan la información pertinente que les permita determinar a que tipo de profesional recurrir de acuerdo a la gravedad y al tipo de afección. De esta manera, un problema relacionado con las relaciones interpersonales será mejor comprendido y atendido por un psicólogo que, por ejemplo, un trastorno derivado por abusos de sustancias.

El hecho de limitar bien los campos de desempeño llevará a un mejor trabajo, con mejores resultados para los usuarios del sistema de salud mental, ya que se evita la redundancia de actividades y posibles conflictos por intromisión considerados de exclusiva responsabilidad por cada profesión.

6.- Referencia bibliográfica

  • Brickmann, H. (1997). Pruebas de evaluación cuantitativa de inteligencia y personalidad. Psicoarchivos. [Documento WWW]. URL http://lightning.prohosting.com/~superte/1sem3/1tecn1.htm
  • Díaz, R., Gayó, R. y otros (1999). Enfoque sistémico: Anorexia. Apsique [Documento WWW]. URL http://www.udec.cl/~clbustos/apsique/pers/anorexia.html
  • Escobar, B. y Cova, F. (1997). Consideraciones epistemológicas y socioculturales de la comprensión de la conducta anormal. Psicoarchivos [Documento WWW]. URL http://lightning.prohosting.com/~superte/2sem3/1anor2.htm
  • Gergen, K. (1994). Realidades y relaciones. Paidós
  • Kaplan, H. y Sadock, B.(1997). Tratado de psiquiatría. Buenos Aires: Inter-médica.
  • Keeny, B.(1987).Estética del cambio. Buenos Aires: Paidós.
  • Lemos, S.(n.d.) Psicopatología. Madrid: Síntesis.
  • Liberman, R.P. (1993). Rehabilitación integral del enfermo mental crónico.Barcelona: Martínez Roca.
  • Martin, B.(1985). Psicología Anormal. Mexico, D.F: Interamericana.
  • Martínez, R. (1998a). Evaluación y diagnóstico e intervención conductual. Psicoarchivos [Documento WWW]. URL http://lightning.prohosting.com/~superte/1sem4/2clin1.htm
  • Martínez, R.(1998b). Fundamentos y encuadre básico de la clínica conductual. Psicoarchivos [Documento WWW]. URL http://lightning.prohosting.com/~superte/1sem4/1clin1.htm
  • Martí-Tusquets, J.L. (1982). Psiquiatría social. Barcelona: Herder.
  • Ministerio de Salud (2000). Plan de Atención psiquátrica para Chile. [Documento WWW]. URL http://www.psiquiatria.cv.cl/
  • Páez, D.(1985). Salud mental y factores psicosociales. España: Fundamentos.
  • Sue, D., Sue, D. Y Sue, S. (1996). Comportamiento anormal. México, D.F.:McGraw-Hill
Imagen de marjuah

me agrado mucho tu trabajo

me agrado mucho tu trabajo esta muy completo, fue de gran utilidad, para mi tarea...

Imagen de César Elguera G.

Los felicito muy interesante

Los felicito muy interesante el artículo.
UNLP-FCM-Legajo 08-44913
Ex-alumno.
Autodidacto.
Lector independiente.
South America
Peru

*Referencias
http://www.fundacionforo.com/mailing/mailing45.html
http://www.psicologia-online.com/Boletines/2010/241210.html
Psiquiatria.com

Imagen de Yolanda Jiménez

excelente artículo, amplio

excelente artículo, amplio y concreto, felicitaciones.

Imagen de amalej

Interesante artículo. Me

Interesante artículo.
Me gustaría preguntarles por los psicólogos en Atención Primaria en su país, dado que estoy realizando una Investigación al respecto, ya que en España son simbólicos los existentes.
Si pueden ayudarme con la frecuencia, funciones concretas a las que están dirigidos,y aquello que se les ocurra me pueda ayudar.
Mi interés actual está centrado en los trastornos por depresión y/o de ansiedad, con tratamiento cognitivo-conductual.
Por supuesto, tomo nota de lo apuntado en el artículo.

Gracias

Amale Jauregui Larrabeiti
Telf. 0034-607 448 929
http://www.psikzain.com
amalej@yahoo.es

Imagen de Marisol Valle Peñaherrera

Tu trabajo es excelente

Tu trabajo es excelente felicitaciones.

Imagen de Introvertido paranoideprofesor psicologo Lenin Ble Vazquez

la informacion bastante

la informacion bastante fundamentada y clara me ha peermitido ubicar los puntos de desempeno en el hospital psiquiatrico. La cual comparto con absoluta certeza, felicidades a los colegas Chilenos.saludos Hospital de alta especialidad en salud Mental -Villahermosa Tabasco.

Imagen de Introvertido paranoideprofesor psicologo Lenin Ble Vazquez

la informacion bastante

la informacion bastante fundamentada y clara me ha peermitido ubicar los puntos de desempeno en el hospital psiquiatrico. La cual comparto con absoluta certeza, felicidades a los colegas Chilenos.saludos Hospital de alta especialidad en salud Mental -Villahermosa Tabasco.

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