Severe mental disorders are frequently associated with individual and systemic costs, with the burden of the disease perceived both emotionally and economically.
The World Health Organization (WHO) and a number of other independent institutions or associations from different countries have regularly reported the impact of mental disorders.
These are just a few data that comprise an objective/critical resource for healthcare policies(1):
About 1 in 5 adults aged 18 to 55 years old develop, at some point during their lifetime, a diagnosable mental disorder (National Institute of Mental Health).
There has been a 13% increase in mental disorders (including the use of substances) over the last decade.
More than 80% of people experiencing severe mental disorders, including those experiencing neurological disorders and use of substances, do not have any accessible, quality mental healthcare.
Four of the 10 main causes of disability (years lost in productive life) in the United States of America and other developed countries are mental disorders, which include major depression, bipolar disorder, schizophrenia and compulsive obsessive disorder (National Institute of Mental Health).
With proper care and treatment, between 70% and 90% of people with severe mental disorders can benefit from a significant reduction in symptoms and an improvement in the quality of life (National Alliance on Mental Illness).
Mental health problems are one of the main causes responsible for the burden of the disease worldwide.
Mental health and behavioural problems (e.g., depression, anxiety and drug use) are reported as the main determinants of disability worldwide, causing more than 40 million years of disability in the 20 to 29 years old age group.
The WHO Special Initiative for Mental Health, designed for the period 2019-2023, builds on all these records, and the vision of this global approach is based on a fundamental concept: the “universal healthcare coverage”(1). The main objective of this initiative is to ensure that all people achieve the highest standard of mental health and well-being.
Statistical determinations on the prevalence of severe mental disorders and on the rate of remission/recovery have proven their importance and impact on healthcare policies. The prioritization of clinical interventions and the creation of new and complex care structures are based on statistical arguments(2).
The history of recovery and rehabilitation concepts development and, later, the Pro-Recovery Movement have greatly changed the vision of severe mental disorders such as schizophrenia: the expectations have become more optimistic, and the chance of recovery has gradually become an objective in schizophrenia management.
Recovery is often conceptualized in the evolutionary sense, as well as clinical recovery equivalent to long-term sustained lack of symptoms.
The term recovery was most often associated with “an approach, a model, a philosophy, a paradigm, a movement, a vision and, sceptically, a myth” (Roberts, 2004)(3).
International studies and assessments of healthcare systems in several countries have pointed to the existing gap between healthcare systems. A significant share of people with severe mental disorders continue to have significant deficiencies in their personal and social functioning for many years after diagnosis and treatment. Paradoxically, the wave of optimism generated by the accessibility to new generation antipsychotics has minimized the role of psychosocial interventions in the management of schizophrenia. The effectiveness of these interventions has been demonstrated by numerous studies and meta-analyses(4).
Moreover, the most important guides to treatment and management of schizophrenia developed according to the principles of evidence-based medicine include, alongside pharmacological treatment, strategies for rehabilitation and social reintegration.
Recovery through rehabilitation
Recovery as a concept has multiple facets and interpretations. Researchers have investigated the cultural dimensions of recovery and the most recent debates have brought the issue of clinical recovery to the fore, versus personal recovery. Objective, symptomatic recovery, quantified and assessed by the clinician, requires a correlation with subjective recovery, as perceived by the suffering person. Some key dimensions of recovery are recognized in various sociocultural contexts: the connection with family, community, spirituality. This also brings differences in developmental models, coping methods, preferences and therapeutic choices, adherence, response to various therapeutic interventions and definitions of positive, and favourable evolution(5).
Large-scale studies, such as the International Pilot Study of Schizophrenia, by WHO, concludes that around 75% of people with schizophrenia get various forms of recovery(6,7). The analysis of the longitudinal evolution data of schizophrenia, carried out by Warner in 2004, concluded that 20% of the subjects achieved full recovery (symptoms solved and returned to the premorbid operational level) and 40% achieved social recovery (economic independence, housing, low level of social marginalization)(8).
There is an opinion trend that personal recovery becomes the main objective of therapeutic interventions, including what this concept entails for the individual: hope, identity, significance, responsibility(9).
Any attempts to define and redefine the evolving stages of severe mental disorders reflect the evolution of healthcare systems with the revolution of modern medicine in the 20th century. The recovery of people experiencing severe mental disorders is becoming a worldwide leitmotif of medical practice.
The philosophy of mental healthcare has been enriched, and the basic concepts have been nuanced and adapted to complex healthcare requirements and needs. Concepts such as patient-centred care, assessment and monitoring, psychiatric rehabilitation, biomedicine are evolving with programs dedicated to people with severe mental disorders. Care locations, structures and teams are starting to be designed according to identified needs, with a focus on greater accessibility and continuity of care. New concepts which they operate today, person-centred care, holistic approach, biopsychosocial approach, case management, psychosocial rehabilitation, infomedicine, are accepted and applied in a comprehensive manner, in line with the global trend toward increasing accessibility to quality healthcare.
The field of psychosocial rehabilitation was born in the years 1960-1970, with the challenge of the massive deinstitutionalization of psychiatric patients launched by outpatient psychiatric services. Some basic elements of rehabilitation have been reported in psychiatric practice over the last century, but they have been on a regular and discrete basis. Mental healthcare has had a journey marked by many controversies and innovations, with different stages of development and progress in time and magnitude. The most important development sequences of psychiatric rehabilitation have generated new patterns of care. From the era of moral therapies and continuing with the Law of vocational rehabilitation, the ideology of community mental healthcare, the psychosocial rehabilitation movement and vocational rehabilitation interventions derived from social learning theory, new interventions have been designed to improve the long-term development of people diagnosed with mental disorders.
Psychosocial rehabilitation is an area that has been difficult to define until recently. The concept of psychosocial rehabilitation encompasses a variety of applicable and acceptable specific care that interacts with the dynamic interaction between the disabled person and his or her living environment(10,11).
There are several models of practice in the vast field of psychosocial rehabilitation, reinforced with programs implemented in different countries through healthcare policies or projects by non-governmental organizations. Examples of programs created in the US, UK or Canada have been taken up and adapted by most countries, resulting in a greater diversity of services and an increased importance and interest in rehabilitation in psychiatric practice.
The principles of psychosocial rehabilitation have been developed and clarified over time, based on concepts and strategies stemming from the central idea that rehabilitation is primarily focused on the overall functionality of the individual. There were a few “currents” that were noticed in a wide range of strategies, with several areas of similarity and common features(12).
A common key aspect is to bring back hope and optimism, with suffering people benefitting from services that make the most of their existing skills and adaptive resources. There are several models of practice in the vast field of psychosocial rehabilitation, reinforced with programs implemented in different countries through healthcare policies or projects by non-governmental organizations(13).
Most of the authors who have addressed rehabilitation in recent decades agree with the idea that patients with severe chronic mental disorders have varying degrees of functional deficit, which becomes the target of rehabilitation. A so-called “reconciliation” of concepts such as activation and progress with those of dependence and acceptance aims to set realistic expectations and objectives, with the optimal access and use of the customer’s capabilities and abilities(13).
Research into psychosocial rehabilitation has been a real challenge. Longitudinal studies have had a particular impact on the perspective of care for people with severe mental disorders in the community. The initiative of these studies, especially over the last 3-4 decades, has created the conditions for modern psychiatric practice.
Independent teams of researchers have reported a positive long-term impact of rehabilitation interventions, especially in people with persistent chronic mental disorders. People with schizophrenia diagnostic and schizophrenic disorder who have benefited from therapeutic rehabilitation programs in a supportive community have had increased recovery rates. Rehabilitation interventions have proven to be effective and have a positive impact on the overall level of operation, but also on the development of new skills, independent living, reintegration into the labour market and time spent in the community(15-19).
Psychosocial rehabilitation has been developed as a set of interventions complementary to psychopharmacologic and psychotherapeutic treatment. The question of whether rehabilitation is different from treatment remains a vast “square” of debate and controversy. Three main opinion streams were identified in the early 90s:
The treatment and rehabilitation are fundamentally different, targeting symptomatology (i.e., functionality); the treatment is associated with minimizing symptomatology, while rehabilitation aims to maximize overall health. There are also arguments supporting this “position”, the most discussed being that of different existing tools for assessment and measurement of symptoms and operation. Moreover, no direct correlation between symptoms and functioning has been identified, and the improvement of one area does not necessarily have a positive impact on the other area in the persons assessed(20,21).
The American psychiatrists have a completely different position, Liberman being one of the opinion leaders with experience in rehabilitation programs. He grants less importance to the distinction between treatment and rehabilitation, bringing into the focus the causal relationship between symptoms and operation, its concern having as a substrate the results of studies carried out by his team(22,23).
However, according to Strauss (1986), the two major areas of intervention intersect with a common area in which the patient and his needs prevail, being helped to develop skills to recognize and control symptoms(24).
These approaches to rehabilitation and its role in psychiatric care are strongly linked to the main models of care: problem-oriented approach, development-focused and environmental focus. The results of the three approaches are solving problems, learning and generating changes, clarifying the role of the individual and integrating into the community(14).
The three approaches can be initiated simultaneously, being complementary, and the customer is defined as the patient involved, aware of himself and informed at each stage of care.
Rehabilitation programs represent, in essence, the “journey” to recovery of the person, thus becoming aware of their own resources and potential for recovery.
Rehabilitation interventions often share common values with the “subjective” recovery model, promoting self-determination and empowerment of the individual. Three operations are recognized, each with different targets and fostering functional recovery: 1) cognitive remediation, 2) psychoeducation and 3) cognitive-behavioural therapies. The tools used for rehabilitation are mainly: problem solving/management, sustained commitment, cognitive remediation, psychoeducation and cognitive therapy(25).
According to Corrigan, psychiatric rehabilitation involves four key structures: objectives, strategies, care structures/settings and roles. Patient-centred care principles can be applied to each of these four structures(11).
Role and mission of psychosocial rehabilitation
After a long period without a unified vision of the concept and the rehabilitation process, the term now describes “a series of responses to the disability issue, from interventions to improve the function of the body to more comprehensive measures to promote inclusion”(1).
The World Health Organization makes a series of recommendations on rehabilitation(26):
Rehabilitation reduces the impact of a wide area of conditions.
Rehabilitation interventions must be accessible immediately after diagnosis at the acute stage of the disease and may be limited to a fixed period or for an indefinite period.
Rehabilitation involves single or multiple interventions provided by specialized teams.
Rehabilitation involves identifying the needs and problems of the person, their relationship with the environment in which the person lives, defining objectives, planning interventions/services and taking appropriate measures, assessing the effects of such measures and interventions.
The education of suffering people and their families is a key and decisive factor in developing self-care and decision-making skills.
People with disabilities and their families must become partners in the rehabilitation process.
Rehabilitation must be accessible at all levels of healthcare, from hospital to community.
Effective rehabilitation can be provided by professionals from several fields, together with the family, friends of the disabled person or groups in the community they live in.
Dimensions of psychosocial rehabilitation
According to the WHO scheme, which describes the steps taken from the onset of the disease to a certain degree of impairment, disability and handicap, rehabilitation would target the disability and handicap of the individual. The concepts of disability and handicap are associated with the person experiencing the disease and with society and its response to perceived disability. In the dynamic relationship between the individual and society, in the context of mental disorder, psychosocial rehabilitation takes place in both directions by increasing the abilities of the individual and reducing the stigmatizing response of society to deactivation. The dimensions addressed in the process of psychosocial rehabilitation must therefore be targeted at areas where disability and handicap are manifested(27).
Three key dimensions of psychosocial rehabilitation are acknowledged:
A mental healthcare system that promotes recovery through rehabilitation must adapt and develop models and services that cover these dimensions. The most appropriate model is the balanced model of care, which has a dynamic that allows running existing services together with the development and progressive addition of new care components at each level.
To be able to cover the rehabilitation needs of persons with severe mental disorders, a medium or higher level of care is required. The components of the mental healthcare system that have the resources that can provide psychosocial rehabilitation services are:
mental health centres
rehabilitation structures in hospitals or healthcare centres for acute or chronic patients
facilities providing long-term care in the community
alternatives to professional recovery and reintegration (vocational rehabilitation, protected jobs)(28).
Mental health centres and rehabilitation as an interface between the healthcare system and the social system
The philosophy of community healthcare in mental health adds to a multitude of principles and practices aimed at promoting the mental health of a population. The network of interconnected and coordinated services, based on multidisciplinary teams, provides complex medical and social services according to the needs, in the natural environment of the beneficiaries (or potential beneficiaries). The provision of mental healthcare in the community is, in itself, a humanitarian model: healthcare is more effective in the long term if provided by keeping the beneficiary in touch with family, friends, colleagues and society.
The essential principles underlying community psychiatric practice are intended to facilitate the recovery and reintegration of the person:
ensuring the needs of the population in an accessible and acceptable manner
relying on the needs and objectives of those experiencing mental illness
creating a network of needs, appropriate support, services and resources
promoting recovery through codes of practice services.
Psychosocial rehabilitation is thus becoming one of the essential components of a comprehensive strategy of community care. Mental health centres are becoming management centres that provide, in addition to the treatment of severe mental disorders, easier access to complex community care resources for both people suffering from mental illness and their families.
The spectrum of existing and accessible rehabilitation programs in mental health centres is very different, depending on the resources. The differences are sometimes significant from country to country, but also within a single country or region.
Romania has connected itself to the worldwide trend of community healthcare for psychiatric patients by publishing in the volume known as the Blue Card of the Ministry of Health Order no. 86/1974 approving the “General rules for the organization and functioning of healthcare units and technical rules in some areas of healthcare”. The organization and functioning framework for mental healthcare laboratories was established, which provides the basic applicable and realistic principles of community psychiatry. The legislative and organizational context encourages interdisciplinarity and continuity of treatment. The specific tasks of Mental Healthcare Laboratories (LSM) as distinct entities covered all areas of intervention (Article 146) from the active detection of risk factors in the appearance of mental disorders and illnesses, active and early detection of mental disorders and illnesses, up to the organization of the ergotherapy activity, according to the law and directing the patients and mental defectives for socio-occupational insertion and reinsertion; follow-up adaptation of improved mental patients in the workplace and society(29).
The prerequirements created over the last 20 years by national legislation, the country reports within WHO and other European bodies level, the support of international bodies and European projects have led to changes in care prospects for all actors involved in the process: beneficiaries and professionals of the mental healthcare system, on the one hand, and local and national authorities on the other. There have been common projects, but also a number of contradictions on how intervention strategies are implemented and on the effectiveness of new community healthcare programs. Psychosocial rehabilitation continued to be a priority component in traditional mental health centres but, at the same time, new rehabilitation structures were created in other mental healthcare centres in the country(29).
The main objective of rehabilitation, undertaken by multidisciplinary teams, is to improve the quality of life of people affected by severe mental illness, providing them with the necessary support to be able to function as actively and independently as possible in society. Rehabilitation programs create a framework that empowers the person with mental disability and, at the same time, identify and develop, together with the patient, support resources for his/her life environment, necessary for reintegration and support in the community(30).
The multidisciplinary team in the mental healthcare centre (CSM) plans and provides intensive care to selected categories of patients, in addition to crisis interventions or other targeted interventions. The duration of interventions will vary according to the degree of disability and the needs identified.
Multiple benefits of mental healthcare centres can be identified for people with severe mental healthcare disorders(28):
Healthcare can be intensive and multidisciplinary, integrating complex assessment and treatment services.
The interventions are personalized and sum-up both pharmacological therapies and individual or family/group psychological therapies, rehabilitation services and occupational therapies.
The patient approach is more flexible, with a variety of alternatives to healthcare programs and their planning.
The continuous interaction with the “non-hospital world” has a significant contribution to the preservation and development of family and social networking skills.
Ensuring continuity of rehabilitation care for chronic patients.
Stigma is less perceived.
Care costs are lower in the long run.
The stages of the rehabilitation process in mental healthcare centres
Psychosocial rehabilitation is based on the idea that each person is motivated or can be motivated to be independent and is able to achieve this objective.
The persons who can benefit from psychosocial rehabilitation services are generally diagnosed with severe mental disorders:
the persons who after the acute phase of the disease require interventions to restore the premorbid functionality;
the persons with chronic mental disorders with severe disability and who need continuous assistance in almost all areas of operation;
the persons maintaining their functionality, but requiring to strengthen and develop skills;
the persons with cognitive disability caused or enhanced by the disease progress;
the persons without personal and/or environmental resources.
Modern rehabilitation is a combination of evidence-based and experienced practices and methods that have proven promising and effective. The combination of interventions may vary, on a case-by-case basis, depending on the individual’s needs and existing resources.
The rehabilitation process is based on several characteristic pillars(11,14):
Rehabilitation is built on the skills of the person, skills that are assessed and developed. Skill training, as a specific area and method of intervention, is designed to improve the social skills of the individual, problem-solving and stress-catching capacity, self-esteem and resilience.
Psychosocial rehabilitation is centred on the individual – it is the assisted person who plays an important role in setting targets based on his/her specific needs. Decisions are shared and taken by all partners in the rehabilitation process. The professionals in rehabilitation structures support these decisions and provide the resources and support needed to achieve the proposed objectives. There are several key areas of intervention: everyday activities, instrumental activities, family and social relationships, education, employment and work, recreational activities and activities to improve overall health and well-being.
Psychosocial rehabilitation is holistic, targeting those areas of the person’s life that can contribute to physical and mental well-being. Access to individual and group psychological services is ensured, but also to other services that are identified in the community.
Rehabilitation through work has positive effects on self-esteem, sense of utility and social belonging. Vocational assistance for people with mental disorders includes the identification and development of vocational skills, assistance in drawing up a career plan, connection with possible community jobs, support for job retention. Training of vocational skills is provided in dedicated structures, for example ergotherapy workshops within mental health centres.
Psychosocial rehabilitation can provide support for finding or maintaining housing. The alternatives are either independent living in their own home or sheltered housing or residential homes/centres.
Social functioning is an important area addressed in the rehabilitation process. Training of social skills brings benefits for better networking within the family and/or couple, the family circle of friends, the educational or professional environment. Skills are trained in verbal and nonverbal communication, the resolution of interpersonal relational problems, the recognition and understanding of emotions, the resolution of problems involving relations with institutions or other structures in the community. This facilitates the creation of a community support network for people with mental disorders who are actively reintegrated into society and significantly improves their quality of life.
A key link to be built with the planning and organization of intervention strategies is the preparation of the community and its integration as a partner in the rehabilitation projects of the multidisciplinary team in mental healthcare centres. This training will involve:
shaping the community as the recipient of primary, secondary or tertiary mental healthcare services
including the community as a partner in the rehabilitation process and transferring from a passive community to an active community
service planning and budgeting and resource generation (volunteers, sponsors etc.).
In the rehabilitation process, professionals will follow four ethical principles that guide any intervention:
respect for the individual’s autonomy
benefit and non-maleficence
The stages of the rehabilitation process require continuous coordination and collaboration, in a system that provides opportunities to maximize the responsibility of the assisted person and encourage its active involvement in the process(31).
The assessment stage:
The assessment uses the interview, anamnesis and heteroanamnesis, the collection of historical data for evolution, direct observation, psychometric and psychodiagnostic tests. Information is collected on the individual’s abilities, support resources and disability. The main aim will be to identify the needs and skills needed by the person being assessed in order to live and operate in his or her living environment.
The planning stage will follow the complex assessment within the multidisciplinary team and will consist of developing a plan, which includes ways of personal change and of the living environment, which will pursue the predefined objective(s) with the assisted person and his/her family. Members of the multidisciplinary team and other partners to be included in the rehabilitation process are identified (family members, friends, family doctor, community members, colleagues). The professionals involved in psychosocial rehabilitation are therapy instructors, occupational therapists, psychiatrists, psychologists, social workers, nurses and other professionals (paralegals, vocational advisors etc.).
The intervention stage consists of the rehabilitation plan and the action implementation, having as final result the improvement and development of the skills of the individual, on the one hand, and increasing support in his/her living environment, on the other hand.
Intervention monitoring will be ensured at intervals set by the team or case manager, so that, depending on the results achieved, the original plan can be continued or changed. The flexibility of the rehabilitation process is an important feature, with the joint efforts of the team and assisted person being adapted according to the factors that may occur along the way or the characteristics (developing, clinically-evolutive or environmental) that were not sufficiently analyzed or assessed at the time of the project initiation.
Studies carried out by independent teams of researchers led to several common conclusions, which are deemed as strong arguments for rehabilitation(31):
People with severe psychiatric disorders can learn new skills.
Skill development interventions significantly improve the rehabilitation process of people with mental disabilities.
The simultaneous development of resources in the life environment of the person with mental disability facilitates rehabilitation and increases the quality of life of the individual in question.
Modern psychiatric practice has the potential to bring together professionals, researchers, healthcare policy makers and healthcare recipients in a framework that places more emphasis than ever on the rehabilitation and dignity of the individual. The integration of psychosocial assessments and interventions into the general services provided in any mental health institution is more than just a specific need, it is a fundamental right of people affected by the burden of mental illness. All rehabilitation interventions should be considered “best practices” and included in the standard treatment of mental disorders.
Psychosocial rehabilitation thus becomes “a legitimate and credible field of practice, education and research”(31) and a compulsory component of any health system.