Principles of Psychosocial Rehabilitation



Principles of Psychosocial RehabilitationRoberta PowerStenberg CollegePrinciples of Psychosocial RehabilitationRecovery from a serious mental illness (SMI) or addiction is a unique and personal journey. Just as SMI and patterns of addiction can present in many different ways, the process of recovery should be an equally individualized plan based on the specific needs of the client. Psychosocial rehabilitation (PSR), also referred to as psychiatric rehabilitation, is a client-centered recovery approach reflective of this concept in that it uses the client’s own stated goals as the basis for planning interventions. Sundeen (2013) defines rehabilitation as the “process of helping the person return to the highest possible level of functioning” (p. 200). This is accomplished by offering services and interventions that address the social, educational, occupational, behavioral, and cognitive aspects of a client’s life, which aims to provide long-term functional ability (Sundeen, 2013). The Mental Health Commission of Canada (MHCC, 2014) also identifies recovery models as central to improving health outcomes for those suffering from mental illness and states, “The MHCC is committed to working with all stakeholders to make recovery and recovery-oriented services a reality across the country” (para. 1). Although psychiatric rehabilitation does not deny the existence or the impact of mental illness, rehabilitation models have changed the perception that this illness means the end of a purposeful life. Rossler (2006) states, “The goal of psychiatric rehabilitation is to help individuals with persistent and serious mental illness to develop the emotional, social and intellectual skills needed to live, learn and work in the community with the least amount of professional support” (p. 151). PSR also offers the essential element of hope to clients who have experienced devastating and debilitating illness; an element that is crucial to the concept of recovery. Compared with the traditional medical model of treatment which focuses on illness, deficits, and symptomology, PSR is a holistic approach that places the client as the focus for treatment with an emphasis on ability, strengths, and personal meaning.AssessmentThe first phase of PSR is assessment where the client’s life goals are identified. By its own definition, PSR is a multidisciplinary approach, but the process often begins with a psychiatric nurse. The nurse and client together must determine the client’s strengths, abilities, hopes, and also potential barriers to fulfilling those goals. An important aspect of assessing a client is determining their ability to perform activities of daily living (ADL) which is a major goal of recovery in helping a client develop independent living skills (Sundeen, 2013). Other factors of assessment include level of self-esteem, socioeconomic status, feelings of stigmatization or discrimination, interpersonal relationships, level of motivation, and level of adherence to medication treatment. A thorough assessment gives the nurse and client a clear picture of where the client is presently, how ready the client is for change, and prioritizes skill development. This process also focuses on the client as a person rather than on the illness, and strives to help the client develop an identity separate from their illness which can impede recovery. “The first task of recovery is developing a positive identity outside of being a person with a mental illness” (Slade, 2009, Box 1). This is a primary difference between traditional medical models of care and the PSR model of recovery. Family and Expressed EmotionAnother important aspect in the assessment is determining the level of family support available to the client. Sundeen (2013) points out that “Approximately 65% of people who have mental illnesses live with their families” (p. 204). Families can be a major source of support for those recovering; therefore, it is imperative that families and caregivers are provided with as much education as possible about the illness, the care plan, and the client’s stated goals. Families can be utilized to identify potential problem areas and encourage the clients’ adherence to medication and treatment plans, as well as being educated on signs of relapse (Sundeen, 2013). Another crucial component of family support is the assessment of expressed emotion (EE) within a family. EE is the degree to which a family or caregiver perceives themselves to be burdened by the client’s illness and needs, and expresses either a high or low level of criticism, blame, or judgement towards the client. Repper and Perkins (2003) explain, “People returning to live in high expressed emotion settings are more likely to relapse within the next nine months than those going to live with families showing low expressed emotion” (p. 125). This is why psychoeducation of not only the client, but their families and caregivers is so imperative. Nurses can also help families experiencing high levels of EE by referring them to resources such as caregiver support groups or respite services. Planning and ImplementationOnce a clear picture emerges as to what the client wishes to accomplish, planning and implementation are the second phase of the PSR model. The goal is to foster independence of the client while ensuring supports are in place to encourage successful outcomes. Sundeen (2013) emphasizes the importance of the nurse and client deciding together on the desired level of functioning, as well as the nurse being sure that the client’s coping skills are adequate enough to deal with the stress of growth and change. Planning could be as simple as joining a support group for socialization and a sense of inclusion, or something more complex such as determining a way to continue in their chosen profession. Whatever the goal, it must be prioritized and acted upon by the client; recovery is not something which is imposed. Another important point in planning and implementation is that it is often referred to as discharge planning to remind the nurse and client that the goal of the plan is ultimately independent functioning (Sundeen, 2013).EvaluationEvaluation is the final phase of the PSR process; however, this phase needs regular revisiting as goals and priorities change for the client. Sundeen (2013) explains both subjective and objective measures should be considered for a clear picture of whether the care plan was effective. Objective measures can be determined by looking at specific questions such as whether the client remained out of the hospital; how social the client has been; whether the client has taken steps towards their goals, etc. Subjective measures are focused on the client’s “perceived quality of life, progress in obtaining life goals, and satisfaction with services rendered” (Sundeen, 2013, p. 212). Evaluations should also be a measure of how well the family or caregivers were served through services and professional staff. Outcome evaluations should measure what matters most to the client, and typically, what matters is a valued social role which contributes to personal identity, meaning, and purpose (Slade, 2009).Community and Social InclusionThe community also greatly influences the recovery journey for clients and their families. Nurses must know what community resources are available to their clients as well as the adequacy and effectiveness of those resources (Sundeen, 2013). Nurses can play a role in advocacy for their clients when community resources are lacking or are inadequate. Sundeen (2013) stresses that a wide range of community services must be available to clients as each person will have varying needs. One client may require basic services such as food, clothing, and shelter whereas another requires vocational, social, or educational resources. The importance of community is that it provides a sense of social inclusion which is a key determinant of health (Mikonnen, Raphael, 2010). Social inclusion enables an otherwise marginalized individual to experience full citizenship, enjoying the same rights and services as others in the community. As well, nurses can act as educators and encourage services within communities to employ an equal access policy. When developing a care plan, assessment of the ability and desire of a client to access services that are important to them within their community will be important for the nurse to know and help facilitate. Case Study“Debra”( “Debra”, personal communication, September, 2014) is a 60-year-old woman who works at the New Life Mission in Kamloops. Her life is in stark contrast to what it was just eight years ago. Debra agreed to an interview to discuss her journey to sobriety and the factors that helped her along the way. Debra was born in Edmonton to alcoholic parents, and although they were not abusive, Debra always felt a sense of shame due to her lower socioeconomic status and felt insecure. She started using drugs and alcohol at the early age of 15, as introduced to her by an older sibling. This immediately included heroin, but progressed to crack cocaine in years to come. Debra did not finish high school and inevitably fell into the life of addiction. She supported her habit in many ways through the years, using prostitution and drug dealing as a means of income. She reports having made large sums of money doing this and estimates she has spent over a million dollars or more on drugs. After ‘successfully’ sustaining her habit in this way, she eventually went to prison on two different occasions, and gave birth to her first of three children while incarcerated. The child was removed from her 10 days later. Upon release from prison, Debra continued her drug habit and became homeless living in Vancouver and then ended up on the streets of Kamloops. At one point in her forties, she was diagnosed as having attention deficit disorder (ADD), and was told this was exacerbated by her drug use and will only worsen as she ages. She eventually suffered further decline in her health, developing an abscess in her throat which extended into her cervical vertebrae. Her hospitalization and surgery to remove two damaged vertebrae from the infection finally prompted her to consider getting help for her addictions. A former friend and drug-user had found help through the New Life Mission, which she frequented, and he encouraged her to enter the women’s recovery program. After a mandatory admission to the Phoenix Centre, the detox centre in Kamloops, Debra entered the Christian-based House of Ruth program for women’s recovery. During her 18 months in the program, Debra learned how to live life without drugs and alcohol. She learned how to cook for herself, manage money, shop for food, socialize, and started working part-time in the job-training program with the House of Ruth; she had never held a regular job. Debra was also able to get her high school diploma. She also found faith in God and credits Him with saving her from a life on the streets. After discharge from the House of Ruth, Debra obtained housing in a low-income apartment building and reports being happy there. Although she is estranged from her three children, one daughter has met with her and introduced her to her grandchild. She is presently working at the New Life Mission and works three hours per day, six days per week. Her ADD and subsequent damage to her brain, prevents her from working longer shifts as she becomes overwhelmed with anxiety. She relayed that the worst times in her life, even with all she had been through, were the times when she felt she had no purpose. Thus, her most important goal in recovery was developing a sense of purpose and she feels she has attained this. The supports she received along her journey instilled her with hope, included her within the community, and focused on her strengths rather than her limitations. Most of all, her recovery journey was her own and she was able to create a manageable life for herself, by her own definition.ConclusionPSR is a client-centered recovery model which facilitates an individualized journey focusing on possibilities for the future rather than the limitations of today. PSR removes the exclusive nature of institutionalization and offers a treatment plan within the community, enabling clients to experience full citizenship. The perception that persons with a mental illness are permanently debilitated is quite prevalent within society, but PSR models of recovery are contradicting those beliefs. Compared with the medical model of treatment which is based on symptoms, limitations, and the illness itself, PSR is a holistic view of the person, focusing on strengths, abilities, and goals. Hope is a central component in the recovery journey, and this can be instilled from many sources such as caregivers, mental health professionals, peers, and within the community itself. Finally, PSR enables clients to imagine and create a new identity, separate from their illnesses, based on their own definition of recovery. ReferencesMental Health Commission of Canada. (2014). , J., & Raphael, D. (2010). Social determinants of health: The Canadian facts. Retrieved from: , J., & Perkins, R. (2003). Facilitating personal adaptation: Taking back control. In Social inclusion and recovery: A model for mental health practice (pp. 109-129). London, UK: Bailliere Tindall.Rossler, W. (2006, October). Psychiatric rehabilitation today: An overview. The World Psychiatric Association, 5(3), 151-157. Retrieved from , M. (2009). 100 ways to support recovery: A guide for mental health professionals. Retrieved from , S. (2013). Recovery Support. In G. Stuart (Ed.), Principles and practice of psychiatric nursing (10th ed. (pp. 199-215). St. Louis, MO: Elsevier Mosby. ................
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