Psychosocial Rehabilitation: Issues and Answers for Psychiatry

Hunter L. McQuistion, MD Medical Director Project Renewal, Inc. Assistant Clinical Professor of Psychiatry The Mount Sinai School of Medicine c/o Project Renewal, Inc. 200 Varick Street New York, NY 10014 (phone): 212-620-0340, (fax): 212-243-4868 (email): hottod@aol.com Robert M. Goisman, MD Director, Outpatient Training and Research Massachusetts Mental Health Center Assistant Professor of Psychiatry Harvard Medical School Boston, MA Clifton R.Tennison, Jr., MD Chief Clinical Officer Helen Ross McNabb Center Clinical Assistant Professor of Medicine (Psychiatry), University of Tennessee Medical Center, Knoxville Clinical Professor of Psychiatry, Quillen School of Medicine, East Tennessee State University Knoxville, TN For the American Association of Community Psychiatrists Task Force on Psychosocial Rehabilitation* *Leona Bachrach, PhD; Gordon Clark, MD, MDiv; Carl Cohen, MD; Katherine Falk, MD; Joel Feiner, MD; Lindsey George, MD; Linda Gochfeld, MD; Robert Goisman, MD; William McFarlane, MD; Hunter McQuistion, MD (chair); Jules Ranz, MD; Barbara Rohland, MD; Ezra Susser, MD, DrPH; Clifton Tennison, MD; Kenneth Thompson, MD ABSTRACT: The American Association of Community Psychiatrists has composed a set of principles to guide psychiatrys relationship with psychosocial rehabilitation. They consist of five basic precepts offering the profession an orientation to rehabilitation, accompanied by seven issues that discuss aspects of how psychiatry must finally adopt psychosocial rehabilitation as a model of practice with people who have severe psychiatric disorders. The authors advance the argument that a confluence of developments, both within and beyond psychiatry, has now created an opportunity for psychiatry to build a mutually productive relationship with rehabilitation.

While combining somatic and psychosocial approaches in severe psychiatric illness has become generally accepted (Mojtabai, Nicholson & Carpenter, 1998), mainstream psychiatry has been slow to truly identify with psychosocial rehabilitation as a model of practice. This exists despite persuasive arguments (Bachrach, 1992, 1996) and useful recommendations (American Psychiatric Association, 1997; International Association of Psychosocial Rehabilitation Services, 1997; Munetz, Birnbaum, & Wyzik, 1993; Torrey, et al., 1998) for integrating clinical psychiatry with rehabilitation. In order to address the relationship of psychiatry and rehabilitation, in 1998, Rodrigo Munoz, MD, president of the American Psychiatric Association (APA), invited the American Association of Community Psychiatrists (AACP) to identify important concerns challenging psychiatry in addressing its relationship to psychosocial rehabilitation. The AACP formed a task force, which drafted a set of Organizing Precepts to guide psychiatrists in orienting themselves to rehabilitation. The task force went on to note some important issues implicit in the precepts. The work of the task force became the basis, in structure and content, for the 1999 Report of the APA Presidential Initiative Advisory Committee on Psychosocial Rehabilitation of the Severely and Persistently Mentally Ill. The AACPs Organizing Precepts begin our paper. The seven issues we consequently discuss, while by no means exhaustive, elucidate the rationale of our Organizing Precepts and constructively address some important problems in psychiatrys orientation to the field. ORGANIZING PRECEPTS: 1. Psychosocial rehabilitation has been defined as "a therapeutic approach that encourages a mentally ill person to develop his or her fullest capacities through learning and environmental supports" (Bachrach, 1996). Psychiatry must adopt this as a basic premise in its work with people who have severe mental illness. In fact, this is so critical that the profession must actively participate in rehabilitations development. 2. Psychiatrists must engage and then build relationships with mental health consumers and, in collaboration with other professionals, help their patients articulate and accomplish their personal goals. 3. Psychiatrists should employ a biopsychosocial model to guide the categorization of goals and to understand their interaction. 4. As physicians, psychiatrists often assume leadership roles while engaging in goal planning among professionals. Given this, psychiatrists should utilize their leadership opportunities to maximize the visibility of rehabilitation as a therapeutic modality. 5. The components of planning continuously developing rehabilitative goals lie on a spectrum from traditional services to nontraditional community resources. Traditional psychiatric tools, like diagnosis, psychopharmacology, psychotherapy, inpatient hospitalization, and health evaluation are discrete interventions within the rehabilitative paradigm. While grounding their work in science, psychiatrists working with patients with severe psychiatric disorders must

understand how to coordinate these interventions with the creative use of other resources in pursuit of enhancing functioning, fostering hope, and helping a person create meaningful identity. Examples of these resources are vocational and social skills training, treatment of cooccurring chemical dependency, specialized housing, peer support mechanisms, and healing modalities that derive from cultural values and spiritual concerns. ISSUES: ISSUE 1: What are the benefits and challenges for psychiatry in building a relationship with others working in psychosocial rehabilitation? Organizing Precept #2 reflects the need for psychiatry to collaborate within the field of psychosocial rehabilitation. Precept #1 includes a mandate to participate in the development of the discipline. Alliance building must be a paramount goal with professions that have defined expertise in rehabilitation. Psychiatrys natural allies in this area include a wide spectrum of workers. These include paraprofessionals as well as trained professionals in rehabilitation therapy, occupational therapy, psychology, nursing, and social work (Blankertz and Robinson 1996). By defining the common ground and respecting differences in expertise, psychiatry can support these professions as they develop practice standards for vocational and psychosocial rehabilitation (Bachrach, 1996). In the past, turf-based histories and traditional ideological and practice conflicts have threatened effective multidisciplinary efforts. Both psychiatric practice and rehabilitation are oriented to long term treatment and maximizing adaptation. This contrasts with the American model of medicine, which often emphasizes pathology and symptom management rather than "wellness," prevention, or functional improvement. Historically, rehabilitations focus on a persons strengths has been perceived as contradictory rather than complementary to the medical mode (Cnaan et al. 1988). If we achieve greater collaboration among psychiatrists and rehabilitation specialists, we can improve consensus on the relative values of clinical diagnosis, functional assessment, and the concept of the medical model in the process of active recovery. Prohibitive separations in funding streams, in reporting and quality assurance mechanisms and in training and certification have also arbitrarily divided the field, impairing consensus and slowing the study and acceptance of practical interventions. Psychiatry can also help develop rehabilitation by reaching out to professional rehabilitation organizations to maximize funding opportunities, to increase visibility for psychiatric rehabilitation, and to explore opportunities to collaborate in a research agenda. Its traditions in science make psychiatry a strong collaborator in research that shows the cost effectiveness of rehabilitative approaches. With the momentum of outcome research, organized psychiatry, together with allied professional groups, can consequently advocate the blending of funding by

policy planners. An example is a coalescence of funding for housing and treatment through capitation. ISSUE 2: How can psychiatry support technologies defined as psychosocial rehabilitation? The literature reveals several valid permutations in defining psychosocial rehabilitation (Anthony, Cohen, & Farkas, 1990; Bachrach, 1996; International Association of Psychosocial Rehabilitation Services, 1994; Liberman, 1998). Furthermore, precept #5 notes that there exists a broad range of rehabilitative modalities, all of which may be subsumed under "rehabilitation" as defined in Precept #1. In order to serve consumers responsibly, any intervention that purports to be a psychosocial rehabilitation technique must have demonstrable efficacy as evidenced by scientific method (Barton, 1999; Munetz et al. 1993). Evidence of the effectiveness of a variety of interventions requires research that is more detailed. Examples of these are interventions in family psychoeducation (Dixon & Lehman, 1995; Mari & Streiner,1994; Penn & Mueser, 1996), vocational training (Baronet & Gerber, 1998), chemical abuse rehabilitation (Drake, Mueser, Clark & Wallach, 1996), assertive community treatment (Baronet & Gerber, 1998; Susser, et. al, 1997), and educational rehabilitation (Baronet & Gerber, 1998). Emerging areas, under more formative exploration, include social skills training (Dilk & Bond, 1996; Liberman, DeRisi & Mueser, 1989; Penn & Mueser, 1996), supportive housing (Cournos, 1987), and cognitive rehabilitation (Bellack, Gold & Buchanan, 1999; Liberman & Green, 1992; Penn & Mueser, 1996; Spaulding,1992). Public sector funding sources increasingly demand quantitative outcomes for psychosocial interventions, reinforcing the necessity of scientific study. Organized psychiatry should lobby major grantors, including pharmaceutical companies, to fund psychosocial research. Another aspect of the argument for empirical evidence is the need to advocate broader use of effective technology within the profession itself. For example, interventions that help families deal with severe mental illness are among the most cost-effective treatments developed but are not used much. Though inadequate funding mechanisms and sparse training opportunities frequently cause this, it is also the case that these interventions are often inconsistent with many clinicians values (McFarlane, et al, 1993). Within the psychiatric community, explication of the synergy between medication and rehabilitation will provide one rationale for coupling essential interventions. For example, atypical antipsychotic agents have the potential to render as candidates for rehabilitation patients who were formerly very ill. These medications can also give people an unvarnished look at what their lives have been like, making effective rehabilitation a humanitarian imperative (Degen & Nasper, 1996; Goisman, 1998). ISSUE 3: What is the relationship of social context in applying psychosocial rehabilitation? Precept #3s crux is the biopsychosocial model, which supports the underlying role of social factors, like socioeconomic status, in the manifestation of many diseases (Link & Phelan, 1995).

Context is an important aspect in the application of rehabilitation. Any intervention that encourages employment must be informed by scientific knowledge on how opportunities to work depend heavily on the economy, the level of wages, the neighborhood, race, gender, and the availability of benefits. Pertinent non-disease issues must be addressed in order to optimize psychiatric rehabilitation (Estroff, 1989; Warner, 1994). Some of the earlier work on mental illness and homelessness attributed homelessness to mental illness. We have learned that the situation is much more complex and the absence of adequate housing and income are key factors in explaining homelessness (Cohen & Thompson,1992). As an epidemiological foundation to Precept #5s inclusion of social and cultural concerns in clinical psychiatry, research in rehabilitation technologies must explore the needs and strengths of defined communities: geographic, ethnic, cultural, and socioeconomic. ISSUE 4: How may clinical psychiatrists involve themselves in psychosocial rehabilitation? Precept #1 implies that mental health professionals, and specifically psychiatrists, must focus on patients' goals, encouraging them to be actively involved in their own care. We may also apply Precept #2 to interdisciplinary teamwork (Bond, 1998; Brown, Goldman, Thompson & Cutler, 1993; Stein & Test, 1976), which has become a leading mode of care, especially in the public sector. In this context, psychiatrists must think broadly and be proactive in the planning and prescription of rehabilitation. This is how the biopsychosocial model operates in practice (Precept #3). For example, environmental stress affects both a persons psychological condition and biological state, including physical health. An integrated response to stress by all members of the therapeutic team can synergistically benefit the affected individuals well being. An assumption may exist among some mental health professionals and decision-makers in rehabilitation that psychiatrists are not flexible enough to participate with such breadth of vision (Bachrach, 1992). Just as many psychiatrists need education about rehabilitation concepts, administrators and allied professionals need to be enlightened about how collaboration is a natural outgrowth of contemporary psychiatrys biopsychosocial approach. One profession alone cannot fully manage the needs of people with severe psychiatric disorders. Another problem in achieving sensitivity to the individual is a structural one. Forces affecting service programs and managed care organizations exert pressure to place people into prefabricated program cubbyholes. This practice is a disincentive for keeping individual goals in the forefront, and as such, becomes an ethical issue (Lazarus & Pollack, 1997). It is a natural role for organized psychiatry to take the lead in developing approaches for meaningful support for ethical practice in programs and health maintenance organizations. Psychiatrists can help lead in staff education on ethical principles. Because consumer alliances pertaining to choice are important, psychiatry can link service programs with consumer organizations. In capitated systems, one mechanism of consumer advocacy is to create independent ombudsman offices to monitor public sector managed care organizations. ISSUE 5: What is the orientation of psychiatric administrators toward psychosocial rehabilitation?

Precept #5 refers to psychiatrists practicing within an array of services over a longitudinal course. As people manage their mental illnesses, they also face a normative progression of challenges throughout life. Services, traditional or nontraditional, must be continuous, and address a person's ever-evolving sense of goals, identity, and connection to people around him or her. Precept #4 reminds us that psychiatrists are often in leadership roles. Psychiatric administrators need to specifically support and value rehabilitation (Goisman, 1998), for example, by incorporating it into agency job descriptions, allowing time off to attend continuing education courses, and in general treat rehabilitation as a mission-related job expectation. Those administrators who are in organized systems must think in terms of creating continuity in services that will enable people to develop over their life span (Anthony & Liberman, 1986; Munetz et al. 1993). These service interventions must be evidence based and focus on improving functioning (Precept #1). Administrators must also understand how to locally adapt such interventions and realize that they can have limitations when transposed to different service environments. Services are too often created and maintained in isolation from each other and programs are under persistent pressure by utilization review to create a "here and now" mentality. Funding streams, especially fee for service mechanisms, create disincentives for linking services. Intramural perspectives within many hospitals and community organizations also impair the process of making connections among providers. Vision and courage must be stimulated. Administrators must look at what will benefit the system of care over the long run and avoid responding only to immediate budget pressures. Psychiatric administrators need to plan services along a full continuum, an approach known ultimately to be cost effective (Barton, 1999; Hawthorne & Hough, 1997). They must actively engage and advocate with local political environments to assure funding for continuous and comprehensive services. As noted above, we believe rehabilitative programming is also community and populationsensitive. Therefore, psychiatric administrators must practice cultural sensitivity and actively develop connections with their local communities in order to develop effective programming. This can involve linking with peer advocacy groups and a variety of non-mental health community resources. Precept #5 notes how such activity can involve creating collaborations with grass-roots organizations like church and neighborhood service groups. ISSUE 6 : How can academic programs address rehabilitation? Psychiatric education must fully embrace psychosocial rehabilitation. This includes continuing education for practicing psychiatrists, systematic education for psychiatric residents, and opportunities for training geared for medical students. This is so basic that it is embodied in all five Organizing Precepts. Foremost among these is Precept #1, which states that psychiatry must accept rehabilitation as an underlying premise in the profession's work with people who have severe mental illness. This

idea is intertwined with the portrayal of traditional interventions and longitudinal practice in Precept #5. That is, any intervention over the course of an illness, including a psychotherapeutic interpretation, an inpatient admission during a crisis, the prescription of a psychotropic medication, or referral to an internist to treat diabetes, pursues rehabilitation: it is aimed at improved long term functioning and satisfaction. Some psychiatrists and psychiatric educators label psychosocial rehabilitation as nonmedical and exclude it from continuing education programs for practicing psychiatrists. Yet, psychiatrists in training at all levels must acquire the broadest armamentarium possible. Residents, for example, should be intimately exposed to effective rehabilitative programs, such as family psychoeducation, transitional employment programs, and assertive community treatment models. Medical school curricula must define rehabilitation precepts and focus on how psychiatric care necessarily involves a longitudinal approach, instilling an appreciation of progressively evolving recovery (Group for the Advancement of Psychiatry, 1993). Medical students need to hear the experiences of professionals and consumers who are involved in rehabilitation. The profession should pursue a number of important potential initiatives. Scientific meetings, like the annual meeting of the APA, should feature the relevance of psychosocial rehabilitation. Industry symposia should include psychosocial rehabilitation in the presentations on psychopharmacology. The AACPs Model Curriculum for training residents in community psychiatry can be used as a starting point in the development of relevant and realistic rotations (Brown et al. 1993). Connections with the American Medical Student Association and the National Medical Student Association should be studied, nurtured and replicated. Nonpsychiatric professionals who are expert in rehabilitation should be introduced into training programs to augment community psychiatry faculty, and roles of medical directors and staff psychiatrists in psychosocial rehabilitation should be highlighted didactically. ISSUE 7: What is psychosocial rehabilitation's role in managed care environments? Consistent with Precept #4, medical directors of managed behavioral healthcare organizations must have true leadership authority to define clinical necessity in the planning and funding of covered interventions. Line psychiatrists working in organized systems of care must also have authority commensurate with their responsibility to provide effective interventions based on individual patients' needs (Clark & Vaccaro, 1987). Poorly designed public sector managed care schemes have been responsible for the destruction of prevention and rehabilitation services (Hawthorne & Hough, 1997). Guaranteed access to the appropriate level of care is essential for treatment that underlies recovery, as described in Precept #5. Managed care programs have presented new risks for under-funding and inadequate treatment, inattention to nontraditional interventions and creative interagency collaborations, and deterioration of efforts that go beyond crisis intervention. However, capitated systems potentially offer unique opportunities to sculpt a variety of traditional and nontraditional services around an enrollee. Mental health managed care organizations, especially those serving the public sector, must have medical directors who can

translate the principles of psychosocial rehabilitation into reimbursement policies. They have a responsibility to monitor the delivery of care to patients, assuring that available services are not only cost efficient but are also effective models consistent with the individual goals of each enrollee (Lazarus & Pollack, 1997). Public sector managed care must be carefully regulated. Managed care contracts should have meaningful and realistic quality assurance components, with financial incentives for good outcomes and penalties for bad outcomes. CONCLUSION: The ideas manifested by the AACPs Organizing Precepts, and discussion of the issues we have identified, offer a framework with which psychiatry can look at rehabilitation with a fresh, updated view. In the past decade psychiatrists have experienced the emergence of important forces influencing mental health care, including greater understanding of brain disease and the documentation of advances in psychosocial techniques. Psychiatrists must also attend to influential social forces. The rise of the family and consumer movements brings a general reorientation of values in health care. In mental health services, these movements resonate with rehabilitations accent on individual goals and personal involvement in recovery, giving rehabilitation a new relevance. Now is the time for psychiatry to incorporate the complementary modality of rehabilitation. It is inextricably tied to the professions future. References American Psychiatric Association (1997). Practice guidelines for the treatment of schizophrenia. American Journal of Psychiatry 154 (Apr. suppl.). Anthony, W, Cohen, M, Farkas, M (1990). Psychiatric Rehabilitation. Boston, Center for Psychiatric Rehabilitation. Anthony, WA, Liberman, RP (1986). The practice of psychiatric rehabilitation: historical, conceptual, and research base. Schizophrenia Bulletin 12: 542-559. Bachrach, LL. Psychosocial rehabilitation and psychiatry in the care of long-term patients (1992). American Journal of Psychiatry 149:11, 1455-146. Bachrach, LL. Psychosocial rehabilitation and psychiatry: what are the boundaries? (1996). Canadian Journal of Psychiatry 41: 28-35. Baronet, AM, Gerber, GJ (1998). psychiatric rehabilitation: efficacy of four models. Clinical Psychology Review 18: 189-228.

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