12 - 28.12 Psychiatric Rehabilitation
28.12 Psychiatric Rehabilitation
with the many possible stories of psychic pain and psychic difference. The more stories clinicians know, the more likely they are to help their clients to find a narrative frame that works for them. For patients and potential service users, a narrative understanding means that there is a range of possible therapists and healing solutions that might be helpful. An approach that is right for one person may not be right for another. There must be a fit between the person and the approach, and people should feel empowered to take seriously their intuitions and feelings. If the person getting help does not feel this fit, he or she is likely right. There may well be another approach that would work better with the person’s proclivities. Like everything else, however, judgment is critical. Therapeutic experiences of all kinds can be frustrating, slow, and uncertain. How, for example, does one know when an approach misses his or her needs and when it is something that will take time, patience, and perseverance to be helpful? From a narrative perspective, there can be no gold standard or simple answers. Only judgment, wisdom, and trial and error can decide. REFERENCES Adler JM, Harmeling LH, Walder-Biesanz I. Narrative meaning making is associated with sudden gains in psychotherapy clients’ mental health under routine clinical conditions. J Consult Clin Psychol. 2013;81(5):839. Alves D, Fernández-Navarro P, Baptista J, Ribeiro E, Sousa I, Gonçalves MM. Innovative moments in grief therapy: the meaning reconstruction approach and the processes of self-narrative transformation. Psychother Res . 2014;24(1):25–41. Boudreau JD, Liben S, Fuks A. A faculty development workshop in narrative-based reflective writing. Perspect Med Educ. 2013;1(3):143–154. Cassel E. The nature of suffering and the goals of medicine. N Engl J Med. 1982;306(11):639. Charon R. Narrative and medicine. N Engl J Med. 2004;350(9):862. Charon R. Narrative medicine: Attention, representation, affiliation. Narrative. 2005;13(3):261. Charon R. Narrative Medicine: Honoring the Stories of Illness. Oxford: Oxford University Press; 2006. Frank AW. Narrative psychiatry: How stories can shape clinical practice (review). Lit Med. 2012;30(1):193–197. Gaines A, Schillace B. Meaning and medicine in a new key: Trauma, disability, and embodied discourse through crosscultural narrative modes. Cult Med Psychiatry. 2013;37(4):580–586. Hansen J. From hinge narrative to habit: Self-oriented narrative psychotherapy meets feminist phenomenological theories of embodiment. Philos Psychiatry Psychol. 2013;20(1):69–73. Hazelton L. Improving clinical care through the stories we tell. CMAJ. 2012; 184(10):1178. Launer J. Narrative diagnosis. Postgrad Med J. 2012;88(1036):115–116. Lewis B. Moving beyond Prozac, DSM, and the New Psychiatry: The Birth of Postpsychiatry. Ann Arbor: University of Michigan Press; 2006. Lewis BL. Narrative psychiatry. In: Sadock BJ, Sadock VA, Ruiz P, eds. Kaplan & Sadock’s Comprehensive Textbook of Psychiatry. 9th ed. Vol. 2. Philadelphia: Lippincott Williams & Wilkins; 2009:2932. Teichman Y. Echoes of the trauma: Relational themes and emotions in children of Holocaust survivors. Psychother Res. 2013;23(1):117–119. 28.12 Psychiatric Rehabilitation
Psychiatric rehabilitation denotes a wide range of interventions designed to help people with disabilities caused by mental illness improve their functioning and quality of life by enabling them to acquire the skills and supports needed to be successful in usual adult roles and in the environments of their choice. Normative adult roles include living independently, attending school, working in competitive jobs, relating to family, having friends, and having intimate relationships. Psychiatric rehabilitation emphasizes independence rather than reliance on professionals, community integration rather than isolation in segregated settings for persons with disabilities, and patient preferences rather than professional goals. VOCATIONAL REHABILITATION Impairment of vocational role performance is a common complication related to schizophrenia. Studies across the United States show that less than 15 percent of patients with severe mental illnesses, such as schizophrenia, are employed. Nevertheless, studies also show that competitive employment is a primary goal for 50 to 75 percent of patients with schizophrenia. Because of patient interests and historical factors, vocational rehabilitation has always been a centerpiece of psychiatric rehabilitation. Antonio is a 45-year-old man who has been a client of a mental health agency for more than 10 years. He attended the rehabilitative day treatment program until it was converted to a supported employment program. His case manager encouraged him to think about the possibility of working part time. Antonio told his case manager that he could not work because of his schizophrenia and because he was helping to raise his two kids and needed to be home at 3 P.M., when they returned from school every day. The case manager explained to Antonio that getting a job does not necessarily mean working 40 hours a week and that lots of people in the agency’s supported employment program were working in part-time jobs, even jobs that only require a few hours a week. Antonio agreed to meet one of the employment specialists to discuss the possibility of work. Over the next couple of weeks, the employment specialist met with Antonio several times, read his clinical record, and talked with his case manager and psychiatrist. The employment specialist learned that Antonio loved to drive his car. He also learned that Antonio had attendance problems in past jobs because he felt unappreciated. The employment specialist found Antonio to be a sociable and likable person. Antonio told the employment specialist that he was willing to do any job. He did not have one specific job in mind. After discussing options with Antonio and with the team, the employment specialist suggested a job at Meals on Wheels as a driver for the lunch delivery. Antonio was hired and loved it right from the start. Absenteeism was never a problem, because he liked driving around and knew that people were counting on him for their meals. The hours were perfect (10 A.M. to 2 P.M.), so he
could be at home when his kids returned from school. He became good friends with the other workers. He told his case manager that it was wonderful to be bringing home a paycheck again. And best of all, he said, was that his kids saw him going to work just like their friends’ dads. (Courtesy of Robert E. Drake, M.D., Ph.D., and Alan S. Bellack, Ph.D.) SOCIAL SKILLS REHABILITATION Social dysfunction is a defining characteristic of schizophrenia. People with the illness have difficulty fulfilling social roles, such as worker, spouse, and friend, and have difficulty meeting their needs when social interaction is required (e.g., negotiating with merchants, requesting assistance to solve problems). Social dysfunction is semiindependent of symptomatology and plays an important role in the course and outcome of the illness. As shown in Table 28.12-1, social competence is based on three component skills: (1) social perception, or receiving skills; (2) social cognition, or processing skills; and (3) behavioral response, or expressive skills. Social perception is the ability to read or decode social inputs accurately. This includes accurate detection of affect cues, such as facial expressions and nuances of voice, gesture, and body posture, as well as verbal content and contextual information. Social cognition involves effective analysis of the social stimulus, integration of current information with historical information, and planning an effective response. This domain is also referred to as social problem solving. Table 28.12-1 Components of Social Skill
Methods The primary modality of social skills training is role play of simulated conversations. The trainer first provides instructions on how to perform the skill and then models the behavior to demonstrate how it is performed. After identifying a relevant social situation in which the skill might be used, the patient engages in role play with the trainer. The trainer next provides feedback and positive reinforcement, which are followed by suggestions for how the response can be improved. The sequence of role play followed by feedback and reinforcement is repeated until the patient can perform the response adequately. Training is typically conducted in small groups (six to eight patients), in which case patients each practice role playing for three to four trials and provide feedback and reinforcement to one another. Teaching is tailored to the individual—for example, a highly impaired group member might simply practice saying “no” to a simple request, whereas a less cognitively impaired peer might learn to negotiate and compromise. Richard was a single white man first diagnosed with schizophrenia at age 22, when he was a freshman at college. He was hospitalized briefly but was unable to return to school and moved back home with his parents. He attended a day treatment program intermittently over the next 6 years, before he was referred for help with getting a job and dating. Richard had missed out on a critical period of adult development and had never learned dating skills or the social skills needed to get or maintain a job. He was
appropriately groomed and did not present himself as a patient, but he seemed quite uncomfortable in social interactions. He scarcely made eye contact, staring at the floor when he spoke, and did not initiate conversation, responding to questions with brief answers. Richard was invited to participate in a social skills training group for 3 months with six other patients. The focus of the group was employment skills. Patients were taught critical social skills for getting and maintaining a job, such as how to participate in job interviews; how to approach a supervisor to understand how to do a job or for help with work-related problems; how and when to make requests or explain problems, such as getting to work late because of traffic or needing to leave early to go to a doctor’s appointment; and socializing with coworkers. Simultaneously, Richard was enrolled in a supported employment program and worked with a case manager to find a job as a computer support person. He found a 24-hour-per-week job at a small company and continued to attend the skills group, using the sessions to work on interpersonal issues at work, including engaging in casual conversation with coworkers and dealing with unreasonable requests from people. When the vocational skills group ended, Richard was scheduled for a dating group with seven other male and female patients who had similar interests. This group focused on finding someone to date, dating etiquette, asking someone out (or being asked out), appropriate conversation for dates, sexual interactions, and safe sex practices. In addition to role play and discussion, the group shared ideas on how to meet people and what to do on dates. Richard responded well to treatment. He had maintained the computer job at follow-up, 6 months after he concluded the dating skills group. His case manger also reported that he had a girlfriend, a woman whom he had met at his church group. He had also expressed an interest in enrolling in college classes at night. He was still living at home with his parents, but, for the first time, was seriously considering what he would need to do to move out. (Courtesy of Robert E. Drake, M.D., Ph.D., and Alan S. Bellack, Ph.D.) Goals In a treatment setting, there are four major goals of social skills training: (1) improved social skills in specific situations, (2) moderate generalization of acquired skills to similar situations, (3) acquisition or relearning of social and conversational skills, and (4) decreased social anxiety. Learning, however, is tedious or almost nonexistent when patients are floridly ill with positive symptoms and high levels of distractibility. Some findings limit the applicability of social skills training. It is more difficult to teach complex conversational skills than to teach briefer, more discrete verbal and nonverbal responses in social situations. Because complex behaviors are more critical for generating social support in the community, methods have been developed to improve the learning and durability of conversational skills. These training methods, focusing on
hour-a-day programs situated in community locales frequented by patients, which provide in vivo support, case management, and training in living skills. Most milieu therapy programs emphasize group and social interaction; rules and expectations are mediated by peer pressure for normalization of adaptation. When patients are viewed as responsible human beings, the patient role becomes blurred. Milieu therapy stresses a patient’s rights to goals and to have freedom of movement and informal relationship with staff; it also emphasizes interdisciplinary participation and goal-oriented, clear communication. Token Economy The use of tokens, points, or credits as secondary or generalized reinforcers can be seen as normalizing a mental hospital or day hospital environment with a program mimicking society’s use of money to meet instrumental needs. Token economies establish the rules and culture of a hospital inpatient unit or partial hospitalization program, offering coherence and consistency to the interdisciplinary team as it struggles to promote therapeutic progress in difficult patients. These programs are challenging to establish, however, and their widespread dissemination has suffered because of the organizational prerequisites and the additional resources and rewards needed to create a truly positively reinforcing environment. Table 28.12-2 lists behaviors that can be reinforced by tokens. Table 28.12-2 Contingencies of Reinforcement in the Token Economy Used at the Camarillo–UCLA Clinical Research Unita
COGNITIVE REHABILITATION Increased recognition of the prevalence and importance of neurocognitive deficits over the past decade has stimulated increasing interest in remediation strategies. Much of the work in this area has focused on psychopharmacological approaches, especially on the new-generation antipsychotics. New-generation medications appear to have a positive effect on neurocognitive test performance, but the effect size for any of the medications is small to medium, and little evidence indicates that these medications have a clinically meaningful impact on neurocognitive functioning in the community. As a result, a parallel interest has arisen in the potential for rehabilitation or cognitive remediation. This body of work is distinguished from cognitive-behavioral therapy and cognitive therapy, which focus on reducing psychotic symptoms. A study at the National Institutes of Health (NIH) found that patients with schizophrenia were unable to benefit from explicit instructions and practice on the Wisconsin Card Sorting Test (WCST), a widely used test of executive functioning. The study was linked to data demonstrating that patients had diminished prefrontal blood flow in dorsolateral prefrontal cortex while responding to the WCST, implying that
schizophrenia was marked by an unmodifiable abnormality of the dorsolateral prefrontal cortex. The NIH work stimulated a series of mostly successful laboratory demonstrations that WCST performance deficits, albeit widespread, are neither endemic to the illness nor immutable. For example, one study demonstrated that WCST performance could be enhanced by financial reinforcement and specific instructions. Other laboratories have since produced comparable and enduring effects using similar training strategies and extended practice alone. ETHICAL ISSUES The ethics of conducting rehabilitation strategies are generally the same as for conducting other psychotherapies. Two issues come up regularly, however: avoiding infantilization and maintaining confidentiality. The first concerns the risk of viewing the patient as unable to make adult choices, such as whether to participate in rehabilitation, where to live, whether or not to work, and whether or not to use drugs and alcohol. Although it may be more of a value than an ethical standard, psychiatric rehabilitation is based on the assumption that the practitioner and the patient are in a partnership to facilitate recovery and improve quality of life. The basic model involves collaboration and shared decision making and does not portray the practitioner as an authority or parental figure. When patients make what appear to be bad choices, the practitioner must consider the patient’s right to choose and whether the choice is dangerous versus simply not the choice the practitioner would make. If the choice, in fact, is potentially harmful, a collaborative process of considering alternatives is more likely to produce good choices than an authoritative, admonitory approach. Failure to consider the patient as a partner also leads to violations of confidentiality. Practitioners sometimes assume that they are the primary arbiters of what information to share with parents, other clinicians, and other agencies. In fact, in most circumstances that do not involve the safety of patients or others, the patient should be the arbiter of what information is shared with whom. For example, in supported employment, the patients always determine whether to disclose information about their illnesses to employers. REFERENCES Becker DR, Drake RE. A Working Life for People with Severe Mental Illness. New York: Oxford University Press; 2003. Blau G, Surges Tatum D, Goldberg CW, Viswanathan K, Karnik S, Aaronson W. Psychiatric rehabilitation practitioner perceptions of frequency and importance of performance domain scales. Psychiatr Rehabil J . 2014;37(1):24–30. Drake RE, Bellack AS. Psychiatric rehabilitation. In: Sadock BJ, Sadock VA, eds. Kaplan & Sadock’s Comprehensive Textbook of Psychiatry. 8th ed. Vol. 1. Philadelphia: Lippincott Williams & Wilkins; 2005:1476. Ganju V. Implementation of evidence-based practices in state mental health systems: Implications for research and effectiveness studies. Schizophr Bull. 2003;29:125–131. Moran GS, Nemec PB. Walking on the sunny side: What positive psychology can contribute to psychiatric rehabilitation concepts and practice. Psychiatric Rehab J. 2013;36(3):202–208. Mueser KT, Noordsy DL, Drake RE, Fox L. Integrated Treatment for Dual Disorders: Effective Intervention for Severe Mental
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