Psychiatric Rehabilitation Idealized: Multi-Setting Uses and Strategies over the Course of Severe Mental Illness.

We describe a fictional case study that illustrates the usefulness of various psychiatric rehabilitation strategies over the long course of treatment for a consumer with chronic mental illness. We also briefly review the literature on specific psychiatric rehabilitation strategies, which share a common goal to minimize the disability associated with severe mental illness and help individuals achieve the highest level of functioning possible. The efficacy of a wide variety of rehabilitation treatments (e.g., social skills training, incentive therapies, cognitive remediation) has been documented in numerous studies. Due to the varied nature of psychiatric rehabilitation interventions, many practitioners of specific rehabilitation strategies may be unaware of the distinctions between them and, when used in appropriate settings, how all of the methods can help clients gradually achieve higher levels of role functioning and autonomy. This article will be useful for mental health professionals, supervisors, and agency leaders as a way to introduce and clarify the use of psychiatric rehabilitation interventions in many different settings and across different phases of client recovery.

Psychiatric rehabilitation is a treatment modality that is drawing the attention of an increasing number of mental health professionals and consumers. The roots of this movement in the United States can be traced back over 150 years to the initial development of moral, humane treatment practices for people with mental illness, which resulted in the creation of an increased number of institutions to house them during the second half of the 19th Century. Over time these institutions became overcrowded and, along with the emergence of effective antipsychotic medications during the mid-20th Century and the ever-increasing costs of psychiatric treatment, this led to the de-institutionalization movement of the 1960s and the resulting focus on community care (Lamb, 1994). The growth of community mental health centers has placed an increased emphasis on finding high-quality, empirically validated, and cost-effective treatments that promote success for mental health consumers in outpatient settings.

A review of past literature shows that psychiatric rehabilitation can include a variety of strategies to address multiple issues in the lives of consumers. These strategies include (but are not limited to) social skills training, psychosocial rehabilitation centers, family education, case management, behavioral interventions, vocational rehabilitation, and cognitive remediation as well as individual and group counseling methods (Silverstein, in press). Leaders in the field of psychiatric rehabilitation have developed effective but distinctly different tools for disseminating rehabilitative treatment to consumers and professionals. Dr. Robert Liberman and his colleagues at UCLA have developed a number of skills training modules and methods over the past 25 years that have been shown to significantly improve the social and coping skills of recipients (Liberman & Corrigan, 1993). Similarly, Dr. William Anthony has led his cohorts at Boston University (Anthony, Cohen, & Farkas, 1990) in creating an effective rehabilitative counseling paradigm that, over the past 20 years, has enabled consumers to play a major role in determining their rehabilitation goals and the steps necessary to achieve them (i.e., skills training and resource development). Dr. Patrick Corrigan at the University of Chicago Center for Psychiatric Rehabilitation has outlined a comprehensive interactive method of staff training that has been shown to be effective in integrating new rehabilitative strategies into pre-existing treatment programs (Corrigan & McCracken, 1997). Numerous studies validate the effectiveness of many psychiatric rehabilitation strategies by documenting that these interventions are associated with reduced rates of relapse, reduced health care costs, improved knowledge of coping and social skills, and better overall prognosis (see Silverstein, Bowman, & McHugh, 1997, and Bedell, Hunter, & Corrigan, 1997, for comprehensive reviews of outcomes).

The vast and varied nature of psychiatric rehabilitation is advantageous in that it provides a wide range of services for clients; on the other hand, such breadth can lead to confusion among treatment professionals about what psychiatric rehabilitation really is. Regardless of the specifics, all methods of psychiatric rehabilitation have a common underlying goal--to minimize the disabling effects of mental illness and promote the highest possible level of role functioning for consumers. Inpatient staff members may implement basic skills training groups and incentive therapies to enhance clients' self-care and social skills to promote discharge. Outpatient and residential program staff may offer more in-depth skills training, behavioral interventions, and family psychoeducation to prevent client relapse and improve community functioning. Rehabilitation counselors may use the goal-oriented approach developed at Boston University to assist clients in achieving greater levels of independence and self-satisfaction (Lamberti, Melburg, & Madi, 1998). These are examples of a wide variety of distinctly different strategies that all work toward helping clients achieve higher levels of role functioning; all are considered to be examples of psychiatric rehabilitation (Silverstein, in press). The challenge for mental health professionals is threefold: a) to become more aware of these strategies and their relative similarities and differences; b) to know who has training and experience in implementing each specific intervention; and, c) to help their clients access these treatments at appropriate points in their recovery process.

It is becoming increasingly apparent that psychiatric rehabilitation should be thought of less as a single treatment `tool' and more as a `tool box' full of interventions that could be useful over the long course of treatment for severe mental illness. Thus, when someone says that they are "trained in psychiatric rehabilitation," more information is necessary. Does this mean that they have extensive experience using the UCLA Social and Instrumental Skills Training Modules, or have they had training at Boston University's Center for Psychiatric Rehabilitation? Have they had experience facilitating psychoeducational groups for family members of their clients? Do they have specific experience in addressing the cognitive impairments often associated with chronic schizophrenia? It would be difficult to find one person with expertise in all of these. Consequently, clarifying the rehabilitative experiences and training among professionals is imperative. This is especially true for administrators who wish to fully utilize their staff members' strengths in the treatment of clients, but also is extremely important for front-line practitioners who may wish to develop expertise in a given area or refer clients to a colleague who has a specific rehabilitation competency.

It is beyond the scope of this article to review in detail each of the modalities and treatment techniques developed across the United States at various treatment and research institutions. However, a brief summary is presented (see Table) with at least one accompanying citation of some of the psychiatric rehabilitation modalities.

Psychiatric Rehabilitation Interventions with References

                                                Methods & time
Intervention            Objective(s)            required

UCLA Social &           Teaching clients        * prepackaged multi-
Instrumental Skills     skills necessary for    media module contains
Training Modules        community integration   all necessary
(Heinssen, Liberman,    and adaptation          materials (trainer's
& Kopelowicz, 2000;     (e.g., Basic            manual, posters,
Liberman & Eckman,      Conversation Skills,    video, workbooks).
1989)                   Interpersonal Problem   * length of workshop
                        Solving, Workplace      varies according to
                        Fundamentals, etc).     topic; typically 1-2
                                                times per week for
                                                4-6 months.

Personal                Teach clients           * role playing
Effectiveness           appropriate and         identified inter-
Training (PET)          effective methods of    personal skills and
(Liberman, King,        self-expression and     modifying through
DeRisi, & McCann,       interpersonal           feedback,
1975)                   communication,          reinforcement, and
                                                shaping.
                                                * best in group
                                                format, 1-2 times
                                                per week, at least
                                                3-4 months.

Intensive Psychiatric   Assist clients in       * rehabilitation
Rehabilitation          pursuing self-          goal-setting and
Training (IPRT)         developed goals in      functional/resource
(Anthony, Cohen, &      living, learning,       assessment
Farkas, 1990;           work, or social         accomplished in
Lamberu, Melburg, &     environments by         either group (e.g.
Madi, 1998)             stressing client        IPRT) or individual
                        choice and assessing/   format.
                        developing necessary    * goals pursued at
                        skills and resources.   pace comfortable to
                                                client; average
                                                length of time in
                                                IPRT program is 6-18
                                                months.

Intervention            Strengths               Potential limitations

UCLA Social &           * groups can be         * severe cognitive
Instrumental Skills     implemented within a    impairments can
Training Modules        pre-existing program    limit effectiveness.
(Heinssen, Liberman,    structure.              * modules range
& Kopelowicz, 2000;     * easily facilitated    in price from
Liberman & Eckman,      by staff with diverse   $300-800 each.
1989)                   backgrounds and
                        training.
                        * empirically
                        supported
                        effectiveness.

Personal                * flexibility of        * in vivo exercises
Effectiveness           material in meeting     and homework
Training (PET)          individual needs of     practice required
(Liberman, King,        clients.                for skill
DeRisi, & McCann,       * emphasis is on        generalization.
1975)                   behaviors and actions   * group co-leaders
                        instead of thoughts     highly recommended.
                        and feelings.

Intensive Psychiatric   * client-centered       * requires client to
Rehabilitation          counseling approach;    set and commit to
Training (IPRT)         rehabilitation goals    realistic goal(s) in
(Anthony, Cohen, &      developed on an         at least one
Farkas, 1990;           individual basis.       environment (living,
Lamberu, Melburg, &     * encourages client     learning, work,
Madi, 1998)             strengths as well as    social).
                        focusing on areas for   * in-depth training
                        improvement.            in Boston model of
                                                psychiatric rehab
                                                may be necessary.

The following case study will help to fully illustrate the distinct roles that various rehabilitation strategies can play in the course of treatment for severe mental illness. While this case is entirely fictional, the elements described in our hypothetical client's psychiatric treatment history reflect common individual uses of rehabilitative tools. However, it is the coordination and timing of various rehabilitation methods that should be kept in mind while considering this case. The case study itself is presented in historical segments followed by an analysis of the rehabilitative tools used during that particular period. As you will see, psychiatric rehabilitation strategies can play an integral role throughout the recovery process in a variety of settings.

CASE STUDY: MR. SMITH

   Mr. Smith is a 34-year-old, African-American male from Rochester, NY, who
   was diagnosed with paranoid schizophrenia in his mid-20s. He has lived with
   his parents for his entire life and has had multiple brief hospitalizations
   up until being admitted to the inpatient unit of a medical center with
   complaints of loud, commanding auditory hallucinations and the belief that
   his family members were "out to get him." He presents as very paranoid,
   agitated, and disheveled upon admission to the medical center and, after 2
   weeks, is transferred to the area state hospital for extended care.

Inpatient Rehabilitation Strategies

During his 8-month stay at the state hospital, Mr. Smith has the opportunity to participate in a number of UCLA group modules, including Grooming, Medication Management, and Basic Conversation Skills. Although Mr. Smith's symptoms make him initially resistant to participating in groups, his knowledge of group material shows improvement after completing these modules, as indicated by significantly higher scores on module post-tests as compared to the corresponding pre-test results. More importantly, direct-care staff members observe practical improvements in daily living skills and Mr. Smith's social abilities. Mr. Smith's symptomatic stability varies over the course of his hospitalization and, consequently, so does his behavior. However, the skills modules give staff members a common reference point from which to request and discuss alternative social behaviors with Mr. Smith (e.g., "Remember in group when we discussed [topic]? Let's try to apply that material to the current situation.").

Mr. Smith's behavioral improvements are particularly noticeable due to the incentive program, or token economy, in operation on his hospital unit. All clients are aware that their `privilege level' (that is, the amount of off-unit and off-grounds time that they are allowed) is based on their behavior from the previous week. The staff has been trained to monitor and record specific program-appropriate client behaviors (e.g., "getting up on time," "passing grooming check," "being on time for morning group," etc.) and to determine clients' privilege levels based on these behaviors. Mr. Smith expresses some initial resistance to these requirements, but the staff notes that Mr. Smith's performance of these behaviors steadily improves over the course of his stay. By the time he is discharged from the state hospital, Mr. Smith's personal hygiene has significantly improved; he is on an effective medication regime; his social abilities have been enhanced, and he is ready to join a community treatment program.

   Upon discharge from the state hospital, Mr. Smith takes up residence in a
   group home and enters a long-term Continuing Day Treatment (CDT) program,
   where he spends the next 5 years. Mr. Smith's family members agree with the
   hospital social worker that a group home is a more appropriate living
   situation for him. The family continues to see him often and remains active
   in his life. Mr. Smith is assigned a psychiatrist, primary therapist, and
   case manager upon being admitted to the CDT program, which he attends 5
   days per week. His family expresses an ongoing desire to emotionally
   support him as much as possible, although they seem confused over the
   nature of his illness and are unsure of the specific nature of his needs.

Outpatient/Day Treatment Rehabilitation Strategies

Many different rehabilitative opportunities are available in the CDT setting during Mr. Smith's course of treatment. Upon admittance to the CDT program, Mr. Smith's counselor administers the Quality of Life Questionnaire (QLQ), a device designed to measure well-being and life satisfaction (Greenly, Greenberg, & Smith, 1997). The QLQ can also serve as a way to evaluate treatment and outcomes over the course of severe mental illness. Various UCLA modules are implemented (Workplace Fundamentals, Interpersonal Problem Solving, Recreation and Leisure, etc.), and Mr. Smith shows further clinical and empirical gains in skills vital to his future success and quality of life. He also attends a Medication Management group to further enhance the skills that he learned in the hospital. Periodically, UCLA modules are offered by the residential staff at the group home. At the CDT, Mr. Smith also has the opportunity to participate in a Personal Effectiveness Training group that focuses on improving interpersonal behaviors by role-playing problem situations relevant to his life. He spends much of the time developing skills to communicate more effectively with his family. In addition to these treatments, the CDT also regularly offers a wide range of other therapeutic, rehabilitative, and recreational groups.

Although Mr. Smith's family remains involved in his treatment, it becomes apparent to his providers that the family is often confused about his symptoms, the recovery process, and what their expectations of him should be. Therefore, all family members are invited to attend a Multiple-Family Psychoeducation group that is co-facilitated by a therapist and case manager and meets every 2 weeks. During these meetings, family members offer each other support and are presented with valuable information regarding diagnoses, symptoms, roles of different mental health professionals, community resources, and crisis management. Furthermore, family members learn about effective communication and problem-solving strategies; they regularly roleplay these strategies during the multiple family group. Eventually, Mr. Smith's family grows to understand the nature of his illness, how to recognize and handle symptoms as they occur, how to effectively discuss their mutual needs, and what types of support they can offer to him and each other.

The CDT program environment also operates a token economy that reinforces pro-therapeutic and appropriate social behaviors among its participants. Although this incentive program is not as extensive as the one he encountered in the state hospital, important independent living skills (e.g., being on time, attending groups, appropriate social behaviors, etc.) are targeted. Mr. Smith already understands the importance of many of these skills and had practiced them successfully during his stay in the hospital. His success within the CDT's token economy is immediate and results in additional recreational activities being available for him (e.g., a trip to the movies for those who earn a certain number of tokens for the week). Staff members often witness Mr. Smith explaining the purpose and benefits of the token economy to newer clients, who are confused by its requirements. Throughout his tenure at the CDT, the Quality of Life Questionnaire is periodically re-administered to monitor his subjective well-being.

   After living in the group home and attending the Continuing Day Treatment
   Program for approximately 18 months, Mr. Smith experiences a severe
   increase in symptoms preceded by extreme paranoia and a refusal to take his
   medications. He is eventually referred to the emergency room by his
   residential counselors and is transferred back to the state hospital for 8
   weeks before returning to the group home.

Short-Term Inpatient Rehabilitation Strategies

During his 8-week hospitalization Mr. Smith participates in additional UCLA module groups, including Community Re-entry, and the unit's comprehensive token economy system. As Mr. Smith's stability increases, he begins to remember and use many of the skills he learned during his previous stay in the hospital and at the CDT program. He also gradually excels on many of the behaviors monitored through the token economy (e.g., hygiene, timeliness, appropriate social behaviors) and re-enters the CDT program upon discharge from the hospital.

   Mr. Smith spends much of his 5 years at the CDT working with the staff to
   further improve his social skills, symptom and medication management,
   relationships with his family members, and other therapeutic issues. After
   spending 2 years in a group home, Mr. Smith achieves admission into a
   closely monitored supported apartment program, where he lives for 3 years.
   His family members continue to attend the biweekly education meetings and
   eventually begin to volunteer their time as fund-raising advocates for a
   local schizophrenia research organization. Mr. Smith spends much of his
   last 2 years at the CDT working at a client-run snack shop on the premises
   and gradually takes on more responsibility in its operations. While this is
   an extremely useful and satisfying experience, he begins thinking, about
   his long-term goals and starts to discuss training and competitive
   employment options with his primary therapist and case manager. Mr. Smith
   is excited but extremely anxious about getting back out into the general
   community and wants time to fully explore his options before making a
   decision. Due to his increased stability and improved functioning, his
   treatment team decides to refer him to an Intensive Psychiatric
   Rehabilitation Treatment (IPRT) program, where he can concentrate on
   researching and pursuing his vocational goals.

Intensive Psychiatric Rehabilitation Treatment (IPRT) strategies

Based on the counseling strategies developed at Boston University's Center for Psychiatric Rehabilitation, an IPRT program helps clients to set and achieve goals in four areas of life: work, education, residential, and social. The program is set up as a `stepping stone' for participants to achieve their goals and get back out into the community doing the things they choose to do. Clients attend the program an average of 3 days per week and participate in goal-oriented and advanced skills-building workshops that are important to success in their goal environment of choice; average length of stay in the program is 18 months. Mr. Smith's psychiatric stability and strong motivation to pursue a work goal identify him as an ideal candidate for IPRT services. He attends a series of observation days to experience the daily activities and responsibilities of the program. He is assigned to a rehabilitation practitioner, who evaluates his readiness for their services and will guide him through the process once he joins the program. Mr. Smith and his practitioner mutually agree that admission to an IPRT is an appropriate treatment option, and he is admitted to the program. He is subsequently transferred from the CDT to a less intensive clinic program at the same agency, where he attends weekly individual sessions with his primary counselor as an adjunct to IPRT. His clinic counselor periodically administers the Quality of Life Questionnaire with consistently more positive results.

Mr. Smith spends the next 2 years at the IPRT working on a variety of self-determined goals. Although he eventually wants to be competitively employed, his initial focus is on increasing his involvement in social activities to fill up non-program time that would normally have been spent in the CDT. Mr. Smith attends IPRT group workshops 3 days per week that focus on skills necessary for him to achieve and maintain his goals (e.g., anxiety and stress management, budgeting, time management, communication skills, etc.). He also attends a workshop devoted exclusively to goal progress and meets with his IPRT practitioner regularly for direction and encouragement. Over the course of 3 to 4 months, Mr. Smith researches a number of options and decides to join a local psychosocial organization (which also offers Personal Effectiveness Training) and pursues a discount membership at the YMCA.

For the remainder of his time in the IPRT program, Mr. Smith concentrates on his goal of getting to work while still attending workshops 3 days per week. He investigates many options ranging from sheltered workshops to regular, competitive employment. After determining his interests and priorities and getting feedback from his family and new clinic treatment team (i.e., psychiatrist, therapist, case manager, residential counselor), Mr. Smith decides to pursue a referral to a sheltered work program funded by the local state hospital. This work program seems to be the ideal option at this time. It will establish a work history in a supported setting while giving him the opportunity to learn a competitive vocational skill (e.g., woodworking and manufacturing furniture). After one and one-half years in the IPRT setting, Mr. Smith starts his new job working three 4-hour shifts per week. He and his case manager closely monitor his earnings so that they will not affect his medical benefits. He continues attending a weekly IPRT support group that helps program members maintain the goals they have achieved and also attends individual therapy sessions at the community clinic once per month.

Case Study Summary

The fictional treatment history outlined above is characterized by a long-term emphasis on psychiatric rehabilitation interventions that encourage Mr. Smith to develop essential daily living and coping skills. The highly structured group modules and incentive programs that were part of his hospitalized treatment laid a foundation of skills required for Mr. Smith to successfully reenter the community and aided in relapse recovery. The family interventions, advanced social skills training, and additional group modules offered by the continuing day treatment program (as well as another token economy) reinforced and expanded the skills that Mr. Smith had learned previously. Finally, the self-motivated, goal-oriented approach used at the Intensive Psychiatric Rehabilitation Program encouraged a stabilized Mr. Smith to set and pursue productive social and vocational goals.

DISCUSSION

The fictional account above describes a realistic course of illness and treatment for someone with severe and persistent mental illness. Many of the empirically supported psychiatric rehabilitation tools that are currently available (see Table) can work together to provide continuity of care and orchestrate an effective course of rehabilitative treatments designed to enhance community-living skills and minimize the disability associated with SPMI. The timing of each particular intervention is of critical clinical importance. Social and independent-living skills training (e.g., UCLA training modules, Personal Effectiveness Training), behavioral interventions (e.g., token economies, shaping and attention-focusing procedures, therapeutic contracting) and cognitive remediation techniques are of central importance when mental illness is at its most disabling level--such as when inpatient treatment or participation in a long-term day treatment program is necessary. These skills can help clients learn (or re-learn) skills essential for community functioning and independent living as well as serve as protective factors against future relapse (Anthony & Liberman, 1986).

For those clients who achieve and maintain a higher, longer-term level of symptomatic stability, the person-centered rehabilitation techniques developed by William Anthony at Boston University would be appropriate, whether individually or in the group-based IPRT form. Some of the treatments mentioned previously (Personal Effectiveness Training, therapeutic contracting, etc.) may also be appropriate at this level of treatment based on their ability to be tailored to the needs of each individual client. It should also be noted that family-based interventions have been shown to be an invaluable component at any point in the recovery process. Thus, while it may seem that the various schools of thought regarding psychiatric rehabilitation are vying with each other for general acceptance among mental health practitioners, these treatment methods can in fact work together (either simultaneously or sequentially) over the course of treatment. Consequently, clients can be presented with increased opportunities to build skills necessary for community integration and increased life satisfaction.

CONCLUSION

The preceding hypothetical case study is designed to emphasize the important role that psychiatric rehabilitation techniques can play in the treatment of mental illness. In order to maximize the impact of these strategies, knowledge and proper training need to be disseminated to staff members in a variety of clinical, residential, vocational, and psychosocial settings. Only by making mental health professionals across a wide range of disciplines more aware of the goals and specific techniques involved in psychiatric rehabilitation methods can these treatments be used effectively in a coordinated effort to enhance clients' quality of life. Used in conjunction with other well-established treatments (e.g., psychotherapy, pharmacology, case management, residential services), psychiatric rehabilitation is an effective treatment option, which can best be viewed as a `box of tools' made up of components which need to be understood individually.

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Rodney Corry is a skills-training consultant and psychiatric rehabilitation practitioner. Thomas C. Jewell, Ph.D., is a senior instructor of Psychiatry at the University of Rochester. Both are consultants for the Staff Training and Rehabilition Project at the University of Rochester Medical Center's Strong Ties Community Support Program, Rochester, NY.