Psychiatric Rehabilitation: A Survey of Rehabilitation Counseling Education Programs.

An estimated 4 to 5 million adults in the United States are considered to have a serious mental illness. Although some gains have been made in service provision for individuals with severe mental illness (SMI), the increasing number of individuals with severe and life-long psychiatric disabilities continues to challenge rehabilitation professionals. Along with other human service workers, rehabilitation counselors are being challenged by the large number of people with severe and life-long mental disorders (Garske, 1999). According to McDonald Wilson, Revell, Jr., Nguyen, and Peterson (1991), vocational rehabilitation programs have demonstrated limited success for people with psychiatric disability, a population that represents the next-to-largest category of disability served by the state-federal vocational rehabilitation (VR) system.

Individuals with severe mental illness may experience deficits in social skills, personal management, symptom management, cognition, and coping with stress (Bond, 1995; Corrigan, Rao, & Lam, 1999). While such individuals may possess the necessary functional competencies, educational qualifications, and have a strong desire to work, many have not been successful in the labor market (Garske, 1999). While there appears to be a consensus among rehabilitation professionals that employment is an important part of life for persons with mental illness (VandenBoom & Lustig, 1997), estimates of unemployment for the working-age members of this population are at a rate of around 85% (National Institute of Disability and Rehabilitation Services, 1993). Even when persons with serious psychiatric disability seek vocational services, they have success rates only about half of those with physical disabilities (Marshak, Bostick, & Turton, 1990).

To help people with severe mental illnesses become and remain contributing members of society, rehabilitation, vocational training, and assistance in work settings are essential. Comprehensive psychiatric rehabilitation programs combined with effective medication management help such individuals meet the challenges of severe mental illness (Liberman, Corrigan, & Schade, 1989). The mission of psychiatric rehabilitation, as defined by Anthony, Cohen, and Farkas (1990), is to assist persons with long-term psychiatric disabilities increase their functioning so they are successful and satisfied in the environments of their choice with the least amount of ongoing professional assistance. Psychiatric rehabilitation typically involves helping individuals gain or improve skill levels, as well as identify and obtain resources and support required to attain their goals (Garske, 1999).

Although it appears that rehabilitation professionals understand the relationship between life adjustment and physical disabilities, rehabilitationists may not understand the principles and practices of psychiatric rehabilitation (Anthony, 1991). Many clients require comprehensive services dealing with a variety of psychosocial and emotional issues before they can focus effectively on vocational issues (Garske, 1999). From a rehabilitation counselor's point of view, it is understandable that the major focus of rehabilitation may be on improving vocational outcomes for people with severe psychiatric disabilities. However, clients who have poor social skills, limited peer relationships and who have difficulty adjusting to community living need more than vocational counseling services.

Today many rehabilitation counselors are working in community mental health centers, psychiatric hospitals, community residential programs, supported employment programs, and community support programs. Based on current trends, qualified rehabilitation counselors will continue to be in demand to work with persons with severe psychiatric disabilities. Psychiatric rehabilitation and case management services are very demanding and complex. Therefore, psychiatric rehabilitation professionals must have advanced training in an array of knowledge areas, including psychopathology, psychopharmacology, medical and psychosocial aspects of disabilities, vocational aspects of disabilities, assessment, intervention techniques, and community resource utilization (Chan, et al., 1999).

According to Anthony, Cohen, and Farkas (1990), a review of the literature attests to the historical omission of psychiatric disabilities in the curricula of most professional training programs. Garske (1992, 1999) recommended that graduate level rehabilitation counselor education programs assess the adequacy of their curricula regarding this specialized preparation. According to Weinberger and Greenwald (1982), only 7 of 59 surveyed graduate level rehabilitation counselor training programs offered a specialty preparation in psychiatric rehabilitation.

The purpose of this research effort was to determine the current status of training in psychiatric rehabilitation provided through CORE accredited rehabilitation counselor education programs. In addition, survey respondents were asked to provide feedback concerning a perceived need for additional training and/or emphasis in psychiatric rehabilitation for future training needs of rehabilitation counselors.

Method

A survey design was employed to ascertain the provision of psychiatric rehabilitation training within the rehabilitation counselor education programs. Data were collected via questionnaires mailed to the 85 rehabilitation counselor education programs identified in the 1997-1998 issue of CORE-Recognized Masters Programs in Rehabilitation Counselor Education.

The brief questionnaire consisted of nine items eliciting specific information concerning (1) course availability and description, (2) where the course is offered (i.e., through the rehabilitation counselor education program or outside the program), and (3) if the course is considered part of a specialty or emphasis area within the rehabilitation counselor education program. Additional items in the questionnaire were designed to obtain information on future training needs in the psychiatric rehabilitation area.

Results

The results of the investigation are based on a return of 61 out of 85 questionnaires, representing a 72% return rate. Of the 61 responses, 24 (39%) of the programs indicated that they offer at least one course related to psychiatric rehabilitation while 37 (61%) do not. Course titles used by these programs are listed in Table 1. Of the 24 programs offering at least one course in psychiatric rehabilitation, 23 of the 24 programs (96%) offer the course through the rehabilitation counselor education program. Six of the 24 (25%) program respondents indicated the psychiatric rehabilitation course is considered part of a specialty or emphasis area within the rehabilitation counselor education program.

Table 1

Psychiatric Rehabilitation Related Course Titles

Psychiatric Rehabilitation (listed 4 times)

Fundamentals of Psychological Rehabilitation

Vocational Implications of Psychiatric Disability

Rehabilitation Approach for Persons with Severe Mental Illness

Medical Aspects of Disabilities (part of course)

Rehabilitation of those with Mental Illness

DSM-IV Diagnosis and Treatment Implications for Counselors

Psychopathology

Principles of Psychiatric Rehabilitation

Vocational Psychiatric Rehabilitation

Twenty-one of the 24 respondents (those providing a course in psychiatric rehabilitation) provided additional information on future training. For example, the titles of textbooks used in courses were listed (see Table 2). Of the 21 respondents, 18 (86%) indicated that psychiatric rehabilitation should be considered an area of specialization in rehabilitation counselor education programs. Of the 24 programs indicating coursework offerings, 14 (58%) indicated a need for additional emphasis (one indicated the emphasis area was already in place), six (25%) indicated no further emphasis was needed, and four (17%) did not respond to the question.

Table 2

Textbooks Used in Psychiatric Rehabilitation Related Courses

American Psychological Association. (1994). Diagnostic and
statistical manual of mental disorders (4th ed.).
Washington, DC: Author.

Andreasen, N., & Black, D. (1995). Introductory textbook of
psychiatry (2nd ed.). Washington, DC: American Psychiatric
Association.

Anthony, W. A., Cohen, M., & Farkas, M. (1990). Psychiatric
rehabilitation. Boston: Boston University.

Anthony W., & Spaniol, L. (1995). Readings in psychiatric
rehabilitation. Boston: Boston University.

Carling, P. J. (1995). Return to community: Building support
systems for people with psychiatric disabilities.
New York: Guilford Press.

Comer, R. J. (1998). Abnormal psychology. New York:
W. H. Freeman & Company.

Ford, L. H. (1995). Providing employment support for people
with long term mental illness. Baltimore: P. H. Brooks.

Hatfield, A. B., & Leftley, H. P. (1993). Surviving mental
illness. New York: Guilford Press.

Kaplan, H. I., & Sadock, B. J. (1998). Kaplan and Sadock's
synopsis of psychiatry: Behavioral sciences, clinical
psychiatry. Baltimore: Lippincott, Williams & Wilkins.

Liberman, R. P. (Ed.). (1992). Handbook of psychiatric
rehabilitation. New York: Macmillan.

Maxmen, J. S., & Ward, N. G. (1995). Essential psychopathology
and its treatment (2nd ed.). New York: Norton & Company.

Morrison, J. (1995). The First Interview: A Guide for Clinicians.
New York: Guilford Press.

Spaniol, L., Gague, C., & Kochler, M. (1997). Psychological and
social aspects of psychiatric disability. Boston: Boston University.

Torrey, E. F. (1988). Nowhere to go: The tragic odyssey of the
homeless mentally ill. New York: Macmillan.

Vinogradov, S., & Yalom, I. D. (1991). Concise guide to
group psychotherapy. Washington, DC: American Psychiatric Press.

Discussion

Survey findings reveal that 39% of the rehabilitation counselor education programs responding to the survey provide at least one training course related to psychiatric rehabilitation, while the majority (61%) of the responding programs do not. The call for an emphasis in psychiatric rehabilitation has clearly been made by a number of researchers spanning more than a decade (Anthony, Cohen, & Farkas, 1990; Chan, Kamnetz, & Jones, 1997; Chan, et al., 1998; Cook & Bolton, 1992; Farkas, O'Brien, & Nemec, 1988; Garske, 1992; Leahy, Chan, Shaw, & Lui, 1997; Leahy, et al., 1997; Szymanski, 1991; Szymanski & Parker, 1989).

With the ever-present pressure to reduce in-patient treatment costs, psychiatric rehabilitation offers great potential in balancing cost containment while providing quality services in managed care systems. According to Anthony (1996a, 1996b), research evidence demonstrates that psychiatric rehabilitation interventions are effective when applied with individuals who have been diagnosed with severe mental illness. The use of traditional approaches alone (e.g., medications, hospitalization, dynamic psychotherapy) has limited effectiveness when applied to the work and socialization aspects of individuals with serious mental illness (Chan, et al., 1998).

Persons with psychiatric disabilities want access to the same housing, work, recreational, and interpersonal experiences as any other member of society (Corrigan, Rao, & Lam, 1997; Deegan, 1992). To facilitate the achievement of such goals, rehabilitation counselors must be knowledgeable of the various types of interventions designed to assist individuals with severe mental illness to overcome disability-related challenges. Such interventions can include skills training (i.e., coping skills, interpersonal skills), medication and symptom management, instrumental and social support, family education and support, transfer training (i.e., generalization), and cognitive rehabilitation (Corrigan, Rao, & Lam, 1999). The goal of training rehabilitation professionals must flow from the goal of rehabilitation. In other words, the goal of training would be to have the practitioners learn the knowledge, skills, and values necessary to effect positive client outcome (Farkas & Anthony, 1980).

Based on the findings of this brief study, only 24 of the 61 responding rehabilitation counselor education programs indicated that they offer at least one course related to psychiatric rehabilitation. These findings appear to be somewhat low considering that the Barden LaFollette Act was passed in 1943. This legislation passed by Congress extended the range of disabilities eligible for rehabilitation services to mental disabilities, including psychiatric disorders. However, the commitment of the state-federal vocational rehabilitation (VR) system to persons with psychiatric disabilities has never seemed complete, even with later legislation (e.g., the Rehabilitation Act of 1973) intended to make this mandate for services clearer (Bond, 1995). The preparation of rehabilitation counselors to provide services for persons with severe mental disorders does not appear appropriate and may contribute to client outcome results. According to McDonald-Wilson, Revell, Jr., Nguygen, and Peterson (1992), vocational rehabilitation programs have demonstrated limited success for people with psychiatric disability, considering that this population is the second largest category reported to be served by the VR system.

Concluding Remarks

Psychiatric rehabilitation can be a complex and formidable task for the rehabilitation counselor. Individuals with severe mental illness often struggle with a wide variety of challenges and needs which likewise challenge the rehabilitation counselor. Such challenges and needs can include assisting the person to learn social skills, interpersonal skills, coping skills, personal hygiene and self-care, as well as symptom and medication management (Corrigan, Rao, & Lam, 1999). The relationship of each of these issues to the rehabilitation process, which may vary from the more traditional process, may cause many rehabilitation counselors to be reluctant to work with this population. For a rehabilitation counselor, the task can seem daunting, especially if adequate training in the complexities and nuances of working with individuals with severe mental illness has not been provided. While the involvement of rehabilitation counselors in psychiatric rehabilitation may prove to be stressful, their involvement seems both appropriate and necessary (Garske, 1992).

Based on the current trend, qualified rehabilitation counselors will continue to be increasingly in demand as part of the community integration team. To make the task faced by rehabilitation counselors easier when working within psychiatric rehabilitation, the following recommendations would appear appropriate. Graduate level rehabilitation counselor training programs should assess the adequacy of their curricula regarding psychiatric disabilities and psychiatric rehabilitation (Garske, 1999). There should be a concerted effort to increase the value of severe psychiatric rehabilitation programming within each rehabilitation counselor education program. These efforts may take a variety of avenues, ranging from establishing a specialized track related to psychiatric rehabilitation to establishing a greater proportion of programming related to severe mental illness within the existing rehabilitation education programs. For such curriculum changes to be made, the current training paradigm will have to be revised. According to Chan, et al. (1999), "Given the demand of the CORE-prescribed rehabilitation curriculum, there may not be room to add these psychiatric rehabilitation-related courses" (p. 342).

A program that cannot provide additional courses within the framework of rehabilitation counseling might include these venues of encouraging rehabilitation counselor students' involvement with psychiatric areas: (1) allow and encourage students to elect courses related to understanding severe mental illness, (2) encourage research papers and projects related to psychiatric rehabilitation in the basic rehabilitation counseling curriculum, and (3) allow students to opt for internship settings which emphasize rehabilitation practices in community psychiatric facilities.

It is clear from the survey that a very limited number of rehabilitation counseling programs offer a specialization in the area of severe psychiatric illness. It is proposed that the Rehabilitation Services Administration (RSA) should be encouraged to direct more training dollars to develop academicians with psychiatric rehabilitation training and experience. Additional program specialization in the area of severe mental illness will not occur without additional qualified or trained faculty. This training might take various forms such as through doctoral training grants or post-doctoral opportunities for existing faculty.

Further, the graduate student leaving a rehabilitation counselor education program needs to be adequately equipped to work with people with severe mental illness. It is recommended that professional organizations be encouraged to request both the certification and accreditation bodies relating to rehabilitation counseling to place more emphasis on the need for knowledge regarding basic psychiatric care and the rehabilitation services related to individuals with severe mental illness.

Finally, the existing faculties in rehabilitation counseling programs nationwide need to recognize the lack of diversity within the faculty regarding understanding and perception of severe mental illness. It is recommended that existing faculty strive to balance their numbers so that appropriate value is placed on providing information and knowledge to students wishing to pursue careers in psychiatric rehabilitation. As Farkas and Anthony (1980) have noted, "Knowledge, attitudes, and skills are all necessary components in preparing students to positively effect client outcome. Training programs need, therefore, to be comprehensive and realistic. If not, they cannot produce practitioners capable of increasing client skill levels or modifying the clients' environments -- the two tasks most relevant to psychiatric rehabilitation outcome" (p. 141).

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Gregory G. Garske
Bowling Green State University

Joseph O. Turpin
California State University - San Bernardino

Connie J. McReynolds, Ph.D., CRC, Rehabilitation Counseling Program, Center for Disability Studies, Department of Educational Foundations and Special Services, Kent State University, 405 White Hall, Kent, OH 44242-0001.