All patients suffering from severe and persistent mental illness require rehabilitation. The goal of psychiatric rehabilitation is to help mentally disabled individuals develop the emotional, social and intellectual skills needed to live, learn and work in communities and societies with the least amount of professional support. The overall philosophy of psychiatric rehabilitation is comprised of two intervention strategies: The first strategy is individual-centered and aims at developing the patient’s skills in coping with a stressful environment. The second strategy is ecological and is directed towards developing environmental resources to reduce potential stressors. Most disabled persons need a combination of both approaches.
The refinement of psychiatric rehabilitation has reached a point where it should be made readily available for every disabled person.
Although psychiatric rehabilitation does not deny the existence or the impact of mental illness, rehabilitation practice has changed the perception of this illness. Enabling persons with persistent and serious mental illness 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. Social role functioning – including social relationships, work and leisure as well as quality of life is of major interest for the mentally disabled individuals living in the community.
Although a 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. Today all patients suffering from severe mental illness (SMI) require rehabilitation. The core group is drawn from patients with persistent psychopathology, marked instability characterized by frequent relapse, and social rejection.
Up to 50% of persons with SMI carry a concomitant diagnosis of substance abuse. The so-called young adult chronic patients constitute an additional category that is diagnostically more complicated. These patients present complex patterns of symptoms difficult to categorize.
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 person is likely to encounter in his or her day-to-day life.
A necessary second step is helping disabled persons to identify their personal goals. This is not a process where those persons simply list their needs. Motivational interviews provide a more sophisticated approach to identify the individuals’ personal costs and benefits associated with the needs listed. This also makes it necessary to assess the individuals’ readiness for change.
Subsequently the rehabilitative planning process focuses on the patient’s strengths. Irrespective of the degree of psychopathology of a given patient, the 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”. 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 a psychiatrist 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 cannot be imposed. Quite the contrary, psychiatric rehabilitation concentrates on the individual’s rights as a respected partner and endorses his or her involvement and self-determination concerning all aspects of the treatment and rehabilitation process. These rehabilitation values are also incorporated in the concept of recovery. 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. The most important factor facilitating recovery is the support of peers. Therefore, psychiatric rehabilitation is also an exercise in network building.
Finally, people with mental disorders and their caregivers prefer to see themselves as consumers of mental health services with an active interest in learning about mental disorders and in selecting the respective treatment approaches. Consumerism allows the taking of the affected persons’ perspective and seriously considering courses of action relevant for them. In this context, physicians should also acknowledge that disagreement about the illness between themselves and the patient is not always the result of the illness.