F-38 Psychiatric rehabilitation

Psychiatry gave birth to psychiatric rehabilitation, rehabilitation services for people with a learning disability, and the biopsychosocial model of illness. Yet, the speciality of rehabilitation has scarcely been involved with psychiatry. This is strange because rehabilitation and psychiatry are both interested in altering behaviour, use a holistic approach to management, and have the goal to optimise social participation through adapting a person’s activities. Rehabilitation experts need experience and expertise in the rehabilitation of people with mental health disorders and learning disability for many reasons. Mental health problems are common, and a significant proportion of people seen in rehabilitation services have mental health difficulties either because of their disabling illness or independently of it. Ideas and approaches used in psychiatric practice broaden the understanding and skills of rehabilitation services. Moreover, many patients seen within mental health or learning disability services will benefit from rehabilitation expertise outside the usual skills of psychiatrists. I hope to show that the rehabilitation process is as applicable to people with drug and alcohol problems or schizophrenia as it is to people with amputations, spinal cord injuries, or stroke.

The competency: psychiatric rehabilitation

The rehabilitation expert is “Able to assess, give advice on, and manage a patient with disturbance of emotion or thought processes affecting behaviour and social interaction.” As with all other areas of rehabilitation, appropriate biomedical specialists remain responsible for disorder-specific diagnosis and treatment, though the distinction between medical and rehabilitation treatments is indistinct. A downloadable document lists some indicative behaviours, knowledge, and skills, and some helpful references.

Introduction

“The aim of rehabilitation is that the disabled person should make the best use of his remaining abilities in as normal a social context as possible.” [Bennett & Morris, 1991]

This quotation is from a book on psychiatric rehabilitation, showing that psychiatric rehabilitation has the same goal as all other rehabilitation branches. Moreover, mental health problems are integral to all other rehabilitation. Last, the biopsychosocial model of illness used in rehabilitation integrates psychological matters, avoiding the Cartesian dualism that occurs in much healthcare.

Given these observations, anyone specialising in any field of rehabilitation must be competent to assess and recommend rehabilitation for a person with mental health problems. They must also be able to recognise mental health diagnoses and the need for disorder-specific treatment and recommend appropriate initial approaches for any patient. Without experience and expertise in mental health, one cannot know when it is appropriate to seek help.

As with many other conditions, rehabilitation is supported by and undertaken in conjunction with services specialised in managing the underlying disorder; in this instance, the disorders needing specialist help include psychoses, severe affective disorders, and other serious conditions, for example, necessitating restrictions under the Mental Health Act.

The need for specialist psychiatric input is met in several ways. Liaison psychiatry has expanded considerably over the last few years, working with most specialities. Although not officially recognised by the General Medical Council, many psychiatrists now practice Neuropsychiatry and run services for people with brain disorders and challenging behaviours. Some doctors have trained in psychiatry and rehabilitation. Clinical psychologists also have a major role to play, though they cannot diagnose or use medication for specific psychiatric diagnoses or be responsible for patients under a section of the Mental Health Act.

History

The need to support people with poor mental health was first recognised and acted on in the 1500s, when places of refuge (asylums) were set up. They offered safety, food, and accommodation, and, in return, inmates were trained to work, such as helping a farm or in the house. In the 1800s, moral therapy was undertaken to achieve “healthy activity of their mental faculties” and return to a social life and employment.

War precipitated an interest in psychiatric rehabilitation, just as it did for other types of rehabilitation. It occurred briefly during the First World War at Craiglockhart in Edinburgh, focusing on people with psychological trauma from the war. Its main goal was to return soldiers to work; vocational rehabilitation has been a strong component of psychiatric rehabilitation since.

In 1944, during the second World War, Thomas Rennie wrote, in the American Journal of Orthopsychiatry, about the need for national planning for psychiatric rehabilitation in the US. He noted that brief psychotherapeutic interventions were often associated with rapid improvement saying, “It is evident that many of these men are spontaneously achieving their own rehabilitation.” This pertinent observation is consistent with the General Theory of Rehabilitation.

Anthony and Liberman, in The Practice of Psychiatric Rehabilitation: Historical, Conceptual, and Research Base, suggest the next primary driver of psychiatric rehabilitation was the move away from long-term institutional care; from about 1970, thousands of people with psychiatric diagnoses moved into the community. This stimulated interest in community, vocational, psychosocial, and skills training rehabilitation.

They state that, by 1986, psychiatric rehabilitation was actively using the biopsychosocial model of illness, had developed a model of mental disorders based on vulnerability, stress, coping, and competence. They outline an approach to people with psychiatric disorders similar to that used in all areas of rehabilitation, with multiple tailored interventions, emphasising social, environmental, and cognitive factors.

Aspects of psychiatric rehabilitation.

Jaap van Weeghel and colleagues recently discussed the concept of recovery, a concept introduced into psychiatric rehabilitation in 1988. They distinguish clinical recovery from personal recovery; this seems to be a contrast between symptoms and social participation. As they say, “… [clinicians] focus on what they perceive as odd experiences, a paucity of internal experience, and psychosocial impairments” but “… [patients] are concerned with loneliness, stigma, and loss of identity.”

They conclude, “Personal recovery entails the idea of learning to live a good life in the face of mental illness. It refers to a process rather than to an outcome, including elements of connectedness, hope and optimism, identity, meaning in life, empowerment, responsible risk taking, and coping with challenges. Recovery-oriented practices should encompass direct work not only with clients but also with families, systems, and communities.”

Rõssler and Drake reviewed psychiatric rehabilitation in Europe and outlined the following principles:

Respect for autonomy
Engagement and relationship, stressing the vital need for trusting and collaborative person relationships between healthcare and patients.
Shared decision-making
Enhancing skills, with an emphasis on doing this where the person will be using the skill.
Support, enhancing the environment including family, friends, and peers.
Increasing opportunities, a political drive to encourage society to offer opportunities.

Marianne Farkas and William Anthony define ‘psychiatric rehabilitation in the context of recovery’. They stress that recovery is a process that happens. They say that “Rehabilitation operates at the intersection between the individual, an individual’s personal network and the wider social context, … is ecological (‘person–environment fit’) and specifically targets improving role performance.”.

Later, they show a process framework. The person:

Chooses a valued role and the provider engages, develops readiness, and sets an overall goal
Gets a valued role, and the provider finds and links with or creates opportunities
Keeps a valued role, and the provider develops skills and supports to help the person succeed

Rehabilitation training of psychiatrists.

Clinicians outside psychiatry should review the only UK curricula relating to rehabilitation to discover their approach and pick up ideas. These curricula are aimed at doctors.

Rehabilitation psychiatry is a recognised subspecialty. In most respects, the curriculum is the same as the general psychiatry curriculum, and many high-level outcomes mirror those in rehabilitation. For example, one says “Apply advanced management skills within Rehabilitation Psychiatry in situations of uncertainty, conflict and complexity across a wide range of clinical and non-clinical contexts.” (see seventh rehabilitation capability)

One specific to rehabilitation psychiatry is “Apply advanced knowledge of relevant legislative frameworks across the UK to safeguard patients and safely manage risk within Rehabilitation Psychiatry.” This includes the Mental Health Act (1983), but it also highlights the importance of safeguarding, which is equally essential in rehabilitation but not mentioned.

Two notable exceptions are the failure to mention the biopsychosocial model of illness, though it refers to being holistic, and the failure to mention multi-professional teamwork; teamwork in general is mentioned.

Although the GMC does not recognise neuropsychiatry, the Royal College of Psychiatrists has published an outline syllabus agreed by The Faculty of Neuropsychiatry, The Association of British Neurologists and The British Neuropsychiatry Association. It mentions “knowledge and applicability of neurorehabilitation” but no more.

The curriculum for psychiatrists specialised in learning disability does not mention rehabilitation, though it must be of central importance.

Evidence

The boundary between biomedical and rehabilitation interventions is nebulous in the absence of definitive curative treatments for the disorder. For example, cognitive behavioural therapy is usually considered rehabilitation, but within psychiatry, it is often mentioned as a treatment.

Vocational rehabilitation, helping people stay in or return to work, is a significant area of work in psychiatry. A Cochrane systematic review entitled Interventions for Obtaining and Maintaining Employment in Adults with Severe Mental Illness, a Network Meta-analysis, found that supported employment with or without augmentation was effective in helping patients obtain or stay in work.

Laurent Morin and Nicolas Franck reviewed rehabilitation interventions for people with schizophrenia. They found evidence that the following benefitted patients:

Cognitive remediation of neurocognitive disorders
Psychoeducation for patients
Family psychoeducation
Social skills training
Cognitive therapy

Another Cochrane systematic review found that adding psychosocial interventions to a pharmacological detoxification programme was associated with benefits across a range of measures.

Last, in an article discussing the challenges and opportunities associated with evidence-based practice in psychiatric rehabilitation, Antonio Vita and Stefano Barlati list 12 intervention strategies supported by evidence (see their Table 1):

Assertive community treatment
Illness self-management training
Cognitive behavioural therapy for psychosis
Family interventions/psychoeducation
Social skills training
Cognitive remediation, including social cognitive and metacognitive training
Supported employment
Physical aerobic exercise, including healthy lifestyle intervention
Integrated early intervention for psychosis
Integrated intervention for comorbidity with Substance Use Disorder
Psychoeducation for bipolar disorder
Functional remediation for bipolar disorder
Dialectical behaviour therapy—skills training groups—for Borderline Personality Disorder

Conclusion

This selected and brief overview of psychiatric rehabilitation supports various conclusions. Psychiatric rehabilitation evolved independently, like most specialist areas of rehabilitation, yet developed a similar set of goals and processes; this supports the propositions that all rehabilitation is similar and that rehabilitation is a necessary part of all healthcare. Psychiatric rehabilitation uses many interventions tailored to a person’s needs and is effective across a range of disorders. This supports similar findings in other areas of rehabilitation. Third, it is integrated with medical psychiatric practice; the biomedical focus of psychiatry is an open and debatable matter, but there are undoubtedly effective, specific pharmacological interventions targeted at the brain, which is the organ associated with mental illness. People training in general rehabilitation can learn much from psychiatric practice, and psychiatric rehabilitation practice could likely learn much from other rehabilitation services.