Rehabilitation techniques
W. Rössler
The goal of psychiatric rehabilitation is to help disabled individuals to establish the emotional, social, and intellectual skills needed to live, learn, and work in the community with the least amount of professional support.(1)
Rehabilitation practice has changed the perception of mental illness. Enabling disabled people to live a normal life in the community causes a shift away from a focus on an illness model towards a model of functional disability. As such, other outcome measures aside from clinical conditions become relevant. Social role functioning including social relationship, work, and leisure as well as quality of life and family burden are of major interest for the people affected living in the community.(25)
The relevance of psychosocial and environmental problems is reflected in the DSM-IV and ICD-10. Axis IV of DSM-IV and codes Z55-Z65 and Z73 of ICD-10 are assigned for reporting psychosocial and environmental problems that may affect the diagnosis, treatment, and prognosis of mental disorders.
The International Classification of Functioning, Disability and Health
Long-term consequences of major mental disorders might be described using different dimensions. A useful tool was provided by the International Classification of Impairment, Disability and Handicaps (ICIDH), first published by the World Health Organization in 1980. The ICIDH has been recently revised. The revised ‘International Classification of Functioning, Disability and Health’ (ICF) includes a change from negative descriptions of impairments, disabilities and handicaps to neutral descriptions of body structure and function, activities and participation. A further change has been the inclusion of a section on environmental factors as part of the classification. This is in recognition of the importance of the role of environmental factors in either facilitating functioning or creating barriers for people with disabilities. Environmental factors interact with a given health condition to create a disability or restore functioning, depending on whether the environmental factor is a facilitator or a barrier.
ICF is a useful tool to comprehend chronically mentally ill in all their dimensions including impairments at the structural or functional level of the body, at the person level concerning activity limitations and at the societal level with respect to restrictions of participation. Each level encompasses a theoretical foundation on which a respective rehabilitative intervention can be formulated.
Target population
During the course of psychiatric reforms the predominant objective of psychiatric rehabilitation was to resettle patients from large custodial institutions to community settings. Today all patients suffering from severe mental illness require rehabilitation. The core group is drawn from patients with the following:
persistent psychopathology
marked instability characterized by frequent relapse
social maladaptation.(28)
There are other definitions currently used to characterize the chronically mentally ill. But they all share some common elements, that is a diagnosis of mental illness, prolonged duration, and role incapacity.
Although the majority of the chronically mentally ill have the diagnosis of schizophrenic disorders, other patient groups with psychotic and non-psychotic disorders are targeted by psychiatric rehabilitation. Up to 50 per cent of people with severe mental illness carry dual diagnoses especially in combination with substance abuse.
The role of the psychiatrist in rehabilitation
Psychiatric rehabilitation is by its very nature, multidisciplinary; because of the many different competencies required. Monitoring medication is a key task of the psychiatrist.
Pharmacotherapy in psychiatric rehabilitation needs some special consideration. Symptom control does not necessarily have the highest priority as some side effects of pharmacological treatment can weaken a person’s ability to perform his social roles, and impair vocational rehabilitation. Many patients living in the community want to take responsibility for their medication themselves. This also includes the varying of medication without consultation within certain limits.
The starting point for an adequate understanding of rehabilitation is that it is concerned with the individual person in the context of his or her specific environment. Psychiatric rehabilitation is regularly carried out under real life conditions. Thus, rehabilitation practitioners have to take into consideration the realistic life circumstances that the affected persons are likely to encounter in their day-to-day living.
A necessary second step is helping disabled persons to identify their personal goals. Motivational interviews provide a sophisticated approach to identify the individuals’ personal costs and benefits associated with the needs listed.(8) This makes it also necessary to assess the individuals’ readiness for change.(15) Functional assessment and individual goal setting are prerequisites of a differentiated rehabilitation intervention plan and should be repeated in different stages of the rehabilitation process.
The rehabilitative planning process focuses on the patient’s strengths. Irrespective of the degree of psychopathology of a given patient, the rehabilitation practitioner must work with the ‘well part of the ego’ as ‘there is always an intact portion of the ego to which treatment and rehabilitation efforts can be directed’ (Lamb 1984(2)). This leads to a closely related concept: the aim of restoring hope to people who suffered major setbacks in self-esteem because of their illness. As Bachrach(2) states ‘it is the kind of hope that comes with learning to accept the fact of one’s illness and one’s limitations and, proceeding from there’.
Psychiatric rehabilitation concentrates on peoples’ rights as a respected partner and endorses their involvement and self-determination concerning all aspects of the treatment and rehabilitation process. These rehabilitation values are also incorporated in the concept of recovery.(9) Within the concept of recovery, the therapeutic alliance plays a crucial role in engaging the patient in his or her own care planning. It is essential that the patient can rely on his or her therapist’s understanding and trust as most of the chronically mentally ill and disabled persons lose close, intimate, and stable relationships in the course of the disease. Recent research has suggested that social support is associated with recovery from chronic diseases, greater life satisfaction, and enhanced ability to cope with life stressors.(24) Therefore, psychiatric rehabilitation is also an exercise in network building.
Current approaches
Psychiatric rehabilitation aims at changing the natural course of the disease. Yet, there is no consensus among rehabilitation researchers on what rehabilitation actually does accomplish. Some understand rehabilitation as an approach to help disabled people to compensate for impairments and to function optimally with the deficiencies they have. Other researchers assume that rehabilitation helps the patient to recover from the disorder itself, while the contributing factors to the healing process are not clear.
The overall philosophy of psychiatric rehabilitation comprises two intervention strategies. The first strategy is individual-centered and aims at developing the patient’s skill to interact with a stressful environment. The second strategy is ecological and is directed towards developing environmental resources to reduce potential stressors. Most disabled people need a combination of both approaches.
As a general rule people with psychiatric disabilities tend to have the same life aspirations as people without disabilities in their society or culture. They want to be respected as autonomous individuals and lead a life as normal as possible. As such they mostly desire (1) their own housing, (2) an adequate education and a meaningful work career, (3) satisfying social and intimate relationships, and (4) participation in community life with full rights.
Housing
The objective of psychiatric reforms since the mid-50s of the 20th century has been to resettle chronically mentally ill persons from large custodial institutions to community settings. Providing sheltered housing in the community for the long-term patients of the old asylums was one of the first steps in the process of deinstitutionalization. Most long-stay patients can successfully leave psychiatric hospitals and live in community settings.
Ideally, a residential continuum (RC) with different housing options should be provided. RC ranges from round-the-clock staffed sheltered homes to more independent and less staffed sheltered apartments, which eventually allow individuals moving to independent housing in the community. Critics of RC contended that (1) up to date RC is rarely available in communities, (2) that RC does not meet the varying and fluctuating needs of persons with serious mental illnesses, and (3) that RC does not account for individuals’ preferences and choices. Supported housing, i.e. independent housing coupled with the provision of support services emerged in the 1980s as an alternative to RC. Supported housing offers flexible and individualized services depending on the individual’s demands. In the meantime, rehabilitation research could demonstrate that supported housing is a realistic goal for the majority of people with psychiatric disabilities.(23) Once in supported housing, the majority stay in housing and are less likely to become hospitalized. Other outcomes do not yield consistent results.
Work
The beneficial effects of work on mental health have been known for centuries.(11) Therefore, vocational rehabilitation has been
a core element of psychiatric rehabilitation since its beginning. Vocational rehabilitation is based on the assumption that work not only improves activity, social contacts, etc., but may also promote gains in related areas such as self-esteem and quality of life, as work and employment are a step away from dependency and a step closer to integration into society. Enhanced self-esteem in turn improves adherence to rehabilitation of individuals with impaired insight.
a core element of psychiatric rehabilitation since its beginning. Vocational rehabilitation is based on the assumption that work not only improves activity, social contacts, etc., but may also promote gains in related areas such as self-esteem and quality of life, as work and employment are a step away from dependency and a step closer to integration into society. Enhanced self-esteem in turn improves adherence to rehabilitation of individuals with impaired insight.
Vocational rehabilitation originated in psychiatric institutions where the lack of activity and stimulation led to apathy and withdrawal of their inpatients. Long before the introduction of medication, occupational and work therapy contributed to sustainable improvements in long-stay inpatients. Today occupational and work therapy are not any longer hospital-based but represent the starting point for a wide variety of rehabilitative techniques teaching vocational skills.
Vocational rehabilitation programs in the community provide a series of graded steps to promote job entry or re-entry. For less disabled persons, brief and focused techniques are used to teach how they can find a job, fill out applications, and conduct employment interviews. In transitional employment, a temporary work environment is provided to teach vocational skills, which should enable the affected person to move on to competitive employment. But all too often, the gap between transitional and competitive employment is so wide that the mentally disabled individuals remain in a temporary work environment. Sheltered workshops providing pre-vocational training also quite often prove a dead end for the disabled persons.
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