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FORUM: PSYCHIATRIC REHABILITATION TODAY

Psychiatric rehabilitation today: an overview


WULF RSSLER
Department of General and Social Psychiatry, University of Zurich, Militrstr. 8, CH-8021 Zurich, Switzerland

All patients suffering from severe and persistent mental illness require rehabilitation. The goal of psychiatric rehabilitation is to help dis-
abled individuals to develop the emotional, social and intellectual skills needed to live, learn and work in the community with the least
amount of professional support. The overall philosophy of psychiatric rehabilitation comprises two intervention strategies. The first strat-
egy is individual-centered and aims at developing the patients skills in interacting with a stressful environment. The second strategy is
ecological and directed towards developing environmental resources to reduce potential stressors. Most disabled persons need a combi-
nation of both approaches. The refinement of psychiatric rehabilitation has achieved a point where it should be made readily available
for every disabled person.

Key words: Psychiatric rehabilitation, severely mentally ill, sheltered housing, supported employment, case management, assertive
community training

The goal of psychiatric rehabilitation Health (ICF) (4) includes a change from cally mentally ill have the diagnosis of
is to help individuals with persistent and negative descriptions of impairments, schizophrenic disorders, other patient
serious mental illness to develop the disabilities and handicaps to neutral de- groups with psychotic and non-psy-
emotional, social and intellectual skills scriptions of body structure and func- chotic disorders are targeted by psychi-
needed to live, learn and work in the tion, activities and participation. A fur- atric rehabilitation. Today all patients
community with the least amount of ther change has been the inclusion of a suffering from severe mental illness
professional support (1). Although psy- section on environmental factors as part (SMI) require rehabilitation. The core
chiatric rehabilitation does not deny the of the classification. This is in recogni- group is drawn from patients with per-
existence or the impact of mental illness, tion of the importance of the role of en- sistent psychopathology, marked insta-
rehabilitation practice has changed the vironmental factors in either facilitating bility characterized by frequent relapse,
perception of this illness. Enabling per- functioning or creating barriers for peo- and social maladaption (5).
sons with persistent and serious mental ple with disabilities. Environmental fac- There are other definitions currently
illness to live a normal life in the com- tors interact with a given health condi- used to characterize the chronically
munity causes a shift away from a focus tion to create a disability or restore func- mentally ill (6). They all share some
on an illness model towards a model of tioning, depending on whether the en- common elements, i.e. a diagnosis of
functional disability (2). Therefore, oth- vironmental factor is a facilitator or a mental illness, prolonged duration and
er outcome measures apart from clinical barrier. role incapacity.
conditions become relevant. Especially The ICF is a useful tool to compre- Up to 50% of persons with SMI car-
social role functioning including social hend chronically mentally ill in all their ry a concomitant diagnosis of sub-
relationships, work and leisure as well dimensions, including impairments at stance abuse (7). The so-called young
as quality of life and family burden is of the structural or functional level of the adult chronic patients constitute an ad-
major interest for the mentally disabled body, at the person level with respect to ditional category that is diagnostically
individuals living in the community. activity limitations, and at the societal more complicated (8). These patients
level with respect to restrictions of par- present complex patterns of symptoma-
ticipation. Each level encompasses a tology difficult to categorize within our
THE INTERNATIONAL theoretical foundation on which a reha- diagnostic and classification systems.
CLASSIFICATION OF FUNCTIONING, bilitative intervention can be formulat- Many of them also have a history of at-
DISABILITY AND HEALTH ed. Interventions can be classified as re- tempted suicide. All in all they repre-
habilitative in the case that they are sent an utmost difficult-to-treat patient
Long-term consequences of major mainly directed towards a functional population.
mental disorders might be described us- improvement of the affected individual.
ing different dimensions. A useful tool As such, the nature of an intervention is
was provided by the International Classi- defined by the goal which is addressed CONCEPTUAL FRAMEWORK
fication of Impairment, Disability and by the intervention.
Handicaps (ICIDH), first published by The overall philosophy of psychiatric
the World Health Organization in 1980 rehabilitation in mental disorders com-
(3). The ICIDH has been recently re- TARGET POPULATION prises two intervention strategies. The
vised. The revised International Classifi- first strategy is individual-centred and
cation of Functioning, Disability and Although the majority of the chroni- aims at developing the patients skills in

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interacting with a stressful environ- his or her own care planning (15). It is ty settings. Providing sheltered housing
ment. The second strategy is ecological essential that the patient can rely on his in the community for the long-term pa-
and directed towards developing envi- or her therapists understanding and tients of the old asylums was one of the
ronmental resources to reduce potential trust (16), as most of the chronically first steps in the process of deinstitu-
stressors. Most disabled persons need a mentally ill and disabled persons lose tionalization. Most long-stay patients
combination of both approaches. close, intimate and stable relationships can successfully leave psychiatric hospi-
The starting point for an adequate in the course of the disease (17). Recent tals and live in community settings (24).
understanding of rehabilitation is that it research has suggested that social sup- Ideally, a residential continuum (RC)
is concerned with the individual person port is associated with recovery from with different housing options should
in the context of his or her specific envi- chronic diseases, greater life satisfaction be provided. RC ranges from round-the-
ronment. Psychiatric rehabilitation is and enhanced ability to cope with life clock staffed sheltered homes to more
regularly carried out under real life con- stressors (18). Corrigan et al (19) have independent and less staffed sheltered
ditions. Thus, rehabilitation practition- found that the most important factor fa- apartments which eventually allow in-
ers have to take into consideration the cilitating recovery is the support of dividuals moving to independent hous-
realistic life circumstances that the af- peers. Therefore, psychiatric rehabilita- ing in the community (25). Critics of RC
fected person is likely to encounter in tion is also an exercise in network build- contended that: a) up to date RC is
his or her day-to-day living (9). ing (20). rarely available in communities, b) RC
A necessary second step is helping Finally, people with mental disorders does not meet the varying and fluctuat-
disabled persons to identify their per- and their caregivers prefer to see them- ing needs of persons with serious men-
sonal goals. This is not a process where selves as consumers of mental health tal illnesses, and c) RC does not account
those persons simply list their needs. services with an active interest in learn- for individuals preferences and choices.
Motivational interviews provide a more ing about mental disorders and in se- Supported housing, i.e. independent
sophisticated approach to identify the lecting the respective treatment ap- housing coupled with the provision of
individuals personal costs and benefits proaches. Consumerism allows the tak- support services (26), emerged in the
associated with the needs listed (10). ing of the affected persons perspective 1980s as an alternative to RC. Support-
This makes it also necessary to assess and seriously considering courses of ac- ed housing offers flexible and individu-
the individuals readiness for change tion relevant for them (21). In this con- alized services depending on the indi-
(11,12). text, physicians should also acknowl- viduals demands. In the meantime, re-
Subsequently the rehabilitative plan- edge that disagreement about the illness habilitation research could demonstrate
ning process focuses on the patients between themselves and the patient is that supported housing is a realistic goal
strengths (9). Irrespective of the degree not always the result of the illness for the majority of people with psychi-
of psychopathology of a given patient, process (22). atric disabilities (27). Once in supported
the practitioner must work with the housing, the majority stay in housing
well part of the ego as there is always and are less likely to become hospital-
an intact portion of the ego to which CURRENT APPROACHES ized. Other outcomes do not yield con-
treatment and rehabilitation efforts can sistent results (27).
be directed (13). This leads to a closely As a general rule, people with psychi-
related concept: the aim of restoring atric disabilities tend to have the same
hope to people who suffered major set- life aspirations as people without dis- Work
backs in self-esteem because of their ill- abilities in their society or culture (23).
ness. As Bachrach (9) states, it is the They want to be respected as au- The beneficial effects of work for
kind of hope that comes with learning to tonomous individuals and lead a life as mental health have been known for
accept the fact of ones illness and ones normal as possible. As such they mostly centuries (28). Therefore, vocational re-
limitations and proceeding from there. desire: a) their own housing, b) an ade- habilitation has been a core element of
Psychiatric rehabilitation cannot be quate education and a meaningful work psychiatric rehabilitation since its be-
imposed. Quite the contrary, psychiatric career, c) satisfying social and intimate ginning. Vocational rehabilitation is
rehabilitation concentrates on the indi- relationships, and d) participation in based on the assumption that work
viduals rights as a respected partner community life with full rights. does not only improve activity, social
and endorses his or her involvement contacts etc., but may also promote
and self-determination concerning all gains in related areas such as self-es-
aspects of the treatment and rehabilita- Housing teem and quality of life, as work and
tion process. These rehabilitation values employment are a step away from de-
are also incorporated in the concept of The objective of psychiatric reforms pendency and a step to integration into
recovery (14). Within the concept of re- since the mid 1950s has been to resettle society. Enhanced self-esteem in turn
covery, the therapeutic alliance plays a chronically mentally ill persons from improves adherence to rehabilitation of
crucial role in engaging the patient in large custodial institutions to communi- individuals with impaired insight (29).

152 World Psychiatry 5:3 - October 2006


Vocational rehabilitation originated crease in the ability to find and keep The results of several controlled stud-
in psychiatric institutions, where the employment (33,34). Links were also ies suggest that disabled individuals can
lack of activity and stimulation led to found between job tenure and non-vo- be taught a wide range of social skills.
apathy and withdrawal of inpatients. cational outcomes, such as improved Social and community functioning im-
Long before the introduction of medica- self-esteem, social integration, relation- prove when the trained skills are rele-
tion, occupational and work therapy ships and control of substance abuse vant for the patients daily life and the
contributed to sustainable improve- (32,35,36). It was also demonstrated environment perceives and reinforces
ments in long-stay inpatients. Today oc- that those who had found long-term the changed behaviour. Unlike medica-
cupational and work therapy are not employment through SE had improved tion effects, benefits from skills training
any longer hospital-based, but represent cognition and quality of life, and better occur slowly. Furthermore, long-term
the starting point for a wide variety of symptom control (32,36). training has to be provided for positive
rehabilitative techniques teaching voca- Although findings regarding SE are effects (31,40-42). Overall, social skills
tional skills (5). encouraging, some critical issues re- training has been shown to be effective
Vocational rehabilitation programs main to be answered. Many individuals in the acquisition and maintenance of
in the community provide a series of in SE obtain unskilled part-time jobs. skills and their transfer to community
graded steps to promote job entry or re- Since most studies only evaluated short life (39,43,44).
entry. For less disabled persons, brief (12-18 months) follow-up periods, the
and focused techniques are used to long-term impact remains unclear. Cur-
teach how they can find a job, fill out rently we do not know which individu- Keeping relationships
applications and conduct employment als benefit from SE and which do not
interviews (30). In transitional employ- (37). After all, we have to realize that As a consequence of deinstitutional-
ment, a temporary work environment is the integration into the labour market ization, the burden of care has increas-
provided to teach vocational skills, does by no means only depend on the ingly fallen on the relatives of the men-
which should enable the affected per- ability of the persons affected to fulfil a tally ill. Informal caregiving significantly
son to move on to competitive employ- work role and on the provision of so- contributes to health care and rehabili-
ment. But all too often the gap between phisticated vocational training and sup- tation (45). Fifty to ninety per cent of
transitional and competitive employ- port techniques, but also on the willing- disabled persons live with their relatives
ment is so wide that the mentally dis- ness of society to integrate its most dis- following acute psychiatric treatment
abled individuals remain in a temporary abled members. (46). This is a task many families do not
work environment. Sheltered work- choose voluntarily. Caregiving imposes
shops providing pre-vocational training a significant burden on families. Those
also quite often prove a dead end for the Building relationships providing informal care face consider-
disabled persons. able adverse health effects, including
One consequence of the difficulties In recent years, social skills training higher levels of stress and depression,
in integrating mentally disabled individ- in psychiatric rehabilitation has be- and lower levels of subjective well be-
uals into the common labour market come very popular and has been wide- ing, physical health and self-efficacy
has been the steady growth of coopera- ly promulgated. The most prominent (47). Additionally, not all families are
tives, which operate commercially with proponent of skills training is Robert equally capable of giving full support for
disabled and non-disabled staff working Liberman, who has designed systemat- their disabled member and willing to re-
together on equal terms and sharing ic and structured skills training since place insufficient health care systems.
management. The mental health profes- the mid 1970s (38). Liberman and his Caregivers regularly experience higher
sionals work in the background, provid- colleagues packaged the skills training levels of burden when they have poor
ing support and expertise (2). in the form of modules with different coping resources and reduced social
Today, the most promising vocation- topics. The modules focus on medica- support (48). But families also represent
al rehabilitation model is supported tion management, symptom manage- support systems, which provide natural
employment (SE). The work of Robert ment, substance abuse management, settings for context-dependent learning
Drake and Deborah Becker decisively basic conversational skills, interper- important for recovery of functioning
influenced the conceptualization of SE. sonal problem solving, friendship and (49). Therefore, there has been a grow-
In their individual placement model, intimacy, recreation and leisure, work- ing interest in helping affected families
disabled persons are placed in compet- place fundamentals, community (re-) since the beginning of care reforms (50).
itive employment according to their entry and family involvement. Each One area of interest deals with the ex-
choices as soon as possible and receive module is composed of skills areas. The pectations of relatives concerning the
all support needed to maintain their skills areas are taught in exercises with provision of care. Relatives quite often
position (31,32). The support provided demonstration videos, role-play and feel ignored, not taken seriously and also
is continued indefinitely. Participation problem solving exercises and in vivo feel insufficiently informed by health pro-
in SE programs is followed by an in- and homework assignments (39). fessionals. They also may feel that their

153
contribution to care is not appreciated or people with mental illness exhibit better focuses on all aspects of the physical and
that they will be blamed for any patient outcomes regarding psychopathology social environment. The core elements
problems. It is no surprise that there is a and quality of life (68). The importance of CM are the assessment of patient
lot of frustration and resentment among of social integration is underlined even needs, the development of comprehen-
relatives considering the physical, finan- more when considering the subjective sive service plans for the patients and
cial and emotional family burden. availability of support: perceived social the arrangement of service delivery (77).
Family intervention programs have support predicts outcome in terms of re- Over the past two decades, a variety
produced promising results. Family in- covery from acute episodes of mental ill- of different models of CM have been de-
terventions are effective in lowering re- ness (69), community integration (70), veloped which exceed the original idea
lapse rate and also in improving out- and quality of life (35,71,72). that CM mainly intends to link the pa-
come, e.g. psychosocial functioning On the basis of comprehensive re- tient to needed services and to coordi-
(51). Possibly, family interventions can search in this area during the last de- nate those services. Today, most clinical
reduce family burden. Furthermore, the cade, several strategies have been devel- case managers also provide direct ser-
treatment gains are fairly stable (52). oped to fight the stigma and discrimina- vices in the patients natural environ-
But we also have to appreciate that it is tion suffered by those who have mental ment. This model is called intensive
not clear what the effective components illnesses (73). Different research centres case management (ICM). ICM is diffi-
of the different models are (53). Addi- developed interventions directed to spe- cult to distinguish from assertive com-
tionally, family interventions differ in cific target groups relevant for destigma- munity treatment (ACT).
frequency and length of treatment. tization, e.g. students (74) or police offi- Stein and Test have developed the ba-
There are also no criteria for the mini- cers (75). Persons in contact with men- sic components of ACT in the 1970s (78).
mum amount of treatment necessary. tally ill individuals quite often have a The original program was designed as a
Finally, we have to be aware that most more positive attitude. Contact with the community-based alternative to hospital
family interventions were developed in mentally ill persons also reduces social treatment for persons with severe mental
the context of Western societies during distance (62), which is a strong argu- illnesses. A comprehensive range of
deinstitutionalization. Family caregiving ment in favour of community psychiatry. treatment, rehabilitation and support
might be quite different in a different cul- Other initiatives have targeted stigma by services in the community is provided
tural context. This refers to other cul- means of more comprehensive pro- through a multidisciplinary team. ACT is
tures in total as well as to minority grams. The WPA launched one of the in- characterized by an assertive outreach
groups in Western societies (45,48,54). ternationally best-known programs in approach, i.e. interventions are mainly
1996 (76). All these initiatives make provided in the natural environment of
clear that efforts in re-integrating per- the disabled individuals (79).
Participation in community life sons with serious mental illness into Research on CM and ACT yielded
with full rights community life must be accompanied by mixed results (80). While the tradi-
measures on the societal level. tional office-based CM approach obvi-
As practitioners, we are often con- ously is less successful, the ACT model
fronted with the deleterious effects of was found to be more beneficial when
stigma and discrimination in the lives of DEVELOPING ENVIRONMENTAL compared with standard care (81). ACT
people with serious mental illnesses. RESOURCES can reduce time in hospital (37), but has
Numerous studies have examined stig- moderate or only little effects on im-
matizing attitudes toward people with Effective psychiatric rehabilitation proving symptomatology and social
mental illness (55-62). In recent years, requires individualized and specialized functioning (82). The differing features
the scientific interest in the perspective treatment, which has to be embedded in of the respective services might explain
of the labeled individual has increased a comprehensive and coordinated sys- the international variation. Six regularly
too. There is extensive empirical evi- tem of rehabilitative services. But, even occurring features of successful services
dence of the negative consequences of when a variety of services are available, were identified: smaller case loads, reg-
labeling and perceived stigmatization. they are poorly linked in many cases, ularly visiting at home, a high percent-
These include demoralization, low qual- and costly duplication may occur. age of contacts at home, responsibility
ity of life, unemployment and reduced While developing community sup- for health and social care, multidiscipli-
social networks (63-67). Once assigned port systems, it became obvious that nary teams and a psychiatrist integrated
the label mental illness and having be- there was a need to coordinate and inte- in the team (83).
come aware of the related negative grate the services provided, as each in-
stereotypes, the affected individuals ex- volved professional concentrates on dif-
pect to be rejected, devaluated or dis- ferent aspects of the same patient. THE ROLE OF THE PSYCHIATRIST
criminated. This vicious cycle decreases Therefore, as a key coordinating and in- IN REHABILITATION
the chance of recovery and normal life. tegrating mechanism, the concept of
On the other hand, well-integrated case management (CM) originated. CM The final ingredient of a successful

154 World Psychiatry 5:3 - October 2006


ACT approach, namely a psychiatrist to symptom control, and not trained in current treatment and rehabilitation
integrated in a community team, in- integrating pharmacological and psy- practice has to be substantially im-
evitably leads to the question: what is or chosocial interventions (88). Another proved in the light of the rehabilitation
can be the role of a psychiatrist in reha- side effect of hospital-based training is research available.
bilitation? According to Cancro (84), that young psychiatrists are confronted
A properly trained psychiatrist will be with the negative developments of diffi-
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