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Psychosocial Rehabilitation

The word rehabilitation literally has two senses: the restoration of dignity and functional recovery.
 
From a historical point of view rehabilitation can be considered

  1. As a movement, aimed at changing the attitude towards persons with mental illness (Bennett, 1983)
  2. As a number of initiatives providing alternatives to institutional care, which have nowadays become known as community mental health services (Bennett & Freeman, 1991)
  3. As a movement to reintegrate persons in the community (Watts & Bennett, 1983, Farkas & Anthony, 1989)
  4. As a body of knowledge of psychosocial interventions aimed at personal and social recovery (Anthony, 1993)

 
Definitions
There are two popular definitions of rehabilitation which are quite often referred to. According to Bennett (1978), the rehabilitation process helps a mentally disabled person to make the most of his or her remaining abilities, so that he or she can attain an optimal level of functioning in the most normal possible setting. Anthony et al. (1990) state that the goal of psychiatric rehabilitation is to improve the functioning of persons with serious psychiatric disabilities so that they can live, learn and work with success and satisfaction in their environment of choice with the least amount of professional intervention possible.
 
These definitions reveal a difference between the two approaches. Bennett defines rehabilitation in terms of an individual’s remaining abilities. The disability is accepted and rehabilitation is aimed at minimizing handicaps. Anthony, however, is more concerned about improving a person’s functioning by reducing the degree of disability. In other words, Anthony’s approach stresses functional recovery.
 
Van Weeghel and Zeelen (1990) also define rehabilitation in terms of functional recovery: rehabilitation is the process of providing care to an individual and influencing his or her environment with the goal of restoring or expanding the individual’s ability to participate in life, work and the community. Van Wel (1994) on the other hand stresses that existing capacities should be optimized: psychiatric rehabilitation is the process in which direct care for the patient is combined with counselling and interventions in the patient’s environment, with the aim of optimizing existing capacities in the most normal possible setting.
 
In 1996, the World Health Organization developed an international consensus document about psychosocial rehabilitation:
Psychosocial rehabilitation is a process that facilitates opportunities for individuals…. to reach their optimal level of independent functioning in the community. It implies both improving individual’s competencies and introducing environmental changes in order to create a life of the best quality for people who have experienced a mental disorder, which produces a certain level of disability. Psychosocial rehabilitation aims to provide the optimal level of functioning of individuals and societies, and the minimization of disabilities and handicaps, stressing individuals’ choices on how to live successfully in the community (WHO, 1996).
 
Basic principles
Psychosocial rehabilitation has a number of basic values and principles, which have been listed by Farkas et al. (1989) and described more fully by Anthony et al. (2002). These principles are widely recognized as being the key values for psychosocial rehabilitation.
 
The first key value reflects rehabilitation as a holistic humanistic approach, in which the individual, although in the role of a receiver of a professional service, is not reduced to the illness or disability part, but is seen as a whole person. The person orientation also includes equality in the sense that the professional, although in the role of a professional service provider, is also a whole person. Seeing each other as individuals, both with strengths and weaknesses, both with valuable experiences, is an important starting point for creating a helping relationship. The professional has to recognize and acknowledge the living world and the experiences of the client, especially with regard to the suffering connected to psychiatric and social problems.
 
Second, rehabilitation is aimed at improving functioning. The focus is on everyday activities. Disabilities are regarded as impediments to use skills which are necessary to execute self-care activities and to live a meaningful life.
 
 

 
Person orientation:  A focus on the human being as a whole, rather than as a diagnostic label or illness.
 
Functioning:  A focus on performance of everyday activities.
 
Support:  A focus on providing assistance for as long as it is needed and wanted.
 
Environmental specificity:  A focus on the specific context of where a person lives, learns, socializes, or works.
 
Involvement:  A focus on including individuals as full partners in all aspects of rehabilitation.
 
Choice:  A focus on the person’s preferences throughout the process.
 
Outcome orientation:  A focus on evaluating rehabilitation in terms of the impact on client outcomes.
 
Growth potential:  A focus on improvement in a person’s success and personal satisfaction, regardless of the person’s current difficulties.
 
Anthony et al. (2002), p. 81; Adapted from Farkas et al. (1989)

 
 
The third value is the provision of support. Besides being a key value, support is also the overall rehabilitation intervention. Support has many different forms, varying from moral support to skills training, from providing financial means to offering assistance to clean the house. Support has a strong service orientation. This is quite another orientation as the therapeutic orientation connected to the medical model. As far as the psychological components of support are concerned, also the subjective perception of support is important. For short: support must be perceived as something helpful, first of all by the person receiving the support, and secondly by the person giving the support. Of course this is valid for every type of intervention, but in rehabilitation it is especially important because of the value of the personal relationship and involvement. In this relationship the professional uses his own personhood as an instrument for offering personal support. Especially in the area of psychological support and counselling, the intervention cannot be separated from the person applying the intervention. The issue of specific and non-specific (therapeutic, in the sense of helpful or supportive) factors, is important in psychosocial rehabilitation, as it seems to be a crucial aspect of recovery oriented services.
 
The fourth key value is environmental specificity. Psychosocial rehabilitation is a contextual approach. The interaction between the individual and his environment is essential. We distinguish between the immediate environment and the larger societal environment. Psychosocial rehabilitation helps a person with a disability to fit in to specific environments, and to fulfil ordinary social roles. As environments we discern the life domains of living, working, learning and socialising. But it is not a one way adaptation. Interventions can also be aimed at adaptation of the environment itself, the so called social interventions. At the level of the society, psychosocial rehabilitation includes actions to reduce stigma and to change legislation. Another reason why environmental specificity is relevant has to do with a certain type of cognitive disability which hinders individuals to generalize skill behaviour. Skills which have been learned in one environment can often not be generalised to another environment (Shepherd, 1990). So for skill development it is important to learn these in the environment where the person lives or works.
                 
The fifth value is involvement. Involvement can also be put in terms of engagement or participation. Again the reciprocity in the relationship is essential. Both, client and professional are involved in an active process. There must be a constant dialogue. Also the persons who are important in the client’s life, such as relatives, who are offering natural support, are involved. Petry speaks about a “triad” and a “trialogue” (Petry and Nuy, 1997). The professional is committed to the goal of the client. The client is involved in every action with regard to the role and activities of the practitioner. Also on a programme and systems level involvement is a key word. Clients must be involved in the development and quality assurance of rehabilitation programmes and rehabilitation services.
 
The sixth value is choice. People with disabilities have the same rights and freedom to make choices as other people. Usually citizenship includes having the right to choose how to live your life, and where to live, where to work or where to go to school. But also to choose how and by whom they want to be supported. The reverse side of the medal is that there is a limited range of choices, as goes for every citizen. Part of the disability may be that underlying cognitive impairments limit the ability of making choices. An important part of a rehabilitation worker will be to provide the person with the skills, supports and information, necessary to create as much “choice ability” as possible. This is also a way of increasing freedom and self-determination. Having the freedom and the ability to make choices is related to motivation, one of the five pillars of a rehabilitation process. The more the person is able to make his own choices, the more motivated he is to set goals and to work actively towards realising these goals. Choice increases involvement.
 
The next value is outcome orientation. Psychosocial rehabilitation is oriented toward a concrete outcome. The provision of personal support and all kinds of services is not an outcome but a way of achieving the rehabilitation outcomes wanted by a client in terms of the desired quality of life and the ability to function in social roles in the community (recovery). Anthony et al. (2002) use the terms success and satisfaction as outcome criteria: “success is measured in terms of the person’s ability to respond to the demands of the chosen environment, while satisfaction is measured in terms of the person’s own reported experience there” (p. 83).
                 
The last value in psychosocial rehabilitation is the belief in people’s potential for growth, or the belief that people can recover from their illness or are able to learn how to live a full life, also with disabilities. Psychosocial rehabilitation is aimed at supporting the client in this recovery process.
 
This text is taken from: Wilken J.P. and D. den Hollander (2005). Rehabilitation and Recovery. Amsterdam: SWP Publishers, p. 11-22.
 
Useful links:
Center for Psychiatric Rehabilitation Boston University: www.bu.edu/cpr
Center for Psychiatric Rehabilitation, Evanston, Illinois: www.enhpsychrehab.org
 
 
last edited by Jean Pierre Wilken March 2013