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Chapter: Essentials of Psychiatry: Psychosocial Rehabilitation

Psychosocial Rehabilitation Strategies

The following sections will briefly describe and evaluate the two types of rehabilitation programs that have had the great-est impact on the field in the 1990s, social skills training and cognitive rehabilitation, and promising directions in vocational rehabilitation.

Rehabilitation Strategies


The following sections will briefly describe and evaluate the two types of rehabilitation programs that have had the great-est impact on the field in the 1990s, social skills training and cognitive rehabilitation, and promising directions in vocational rehabilitation.


Social Skills Training


The most useful perspective for understanding social functioning and social dysfunction in the illness has been the “social skills model” (Meier and Hope, 1998; Morrison and Bellack, 1984). Social skills are specific response capabilities necessary for effective performance. They include verbal response skills (e.g., the ability to start a conversation or to say “No” when needed), paralinguistic skills (e.g., use of appropriate voice volume and in-tonation) and nonverbal skills (e.g., appropriate use of gaze, hand gestures and facial expressions). These skills tend to be stable over time and make a unique contribution to the performance of social roles and quality of life (Bellack et al., 1990; Mueser et al., 1991). Increasing social competence and improving social role functioning has been a major focus of rehabilitation efforts for the past 25 years, and a well-developed technology for teaching social skills has been developed and empirically tested: social skills training (SST) (Bellack et al., 1997; Liberman, 1995).


Social skills training is a highly structured educational procedure that is generally conducted in small groups. Complex social repertoires such as making friends and dating are broken down into steps or component elements such as maintaining eye contact and asking questions. Patients are first taught to perform the elements and then gradually learn smoothly to combine them. Each session has a specific focus such as how to initiate conversations with strangers and how to refuse an unreason-able request. Trainers are more like teachers than traditional therapists. They first give patients simple instructions about how the behavior is to be performed, then they model appropri-ate behavior in a simulated conversation, and then they engage patients in role playing of simulated social encounters as a vehi-cle for practicing new skills. The therapists provide social rein-forcement after each role played response and shape improved performance.


SST is clearly effective in increasing the use of specific behaviors (e.g., gaze, asking questions, voice volume) and improving functioning in the specific domains that are the primary focus of the treatment (e.g., conversational skill, ability to perform on a job interview). However, it is unclear whether other more diffuse dimensions of social functioning are affected, or the extent to which learning in the clinic translates into improved role functioning in the community. The effects of SST on relapse rate and symptoms appear to be negligible, although this is not surprising given the narrow focus of the intervention. SST is clearly an effective teaching technology that is well-received by both patients and clinicians. Nevertheless, it may well be that no time-limited, compartmentalized, office-based treatment can have broad-based effects.


Liberman and colleagues (2001) have approached the problem of generalization with an innovative approach referred to as in vivo amplified skills training (IVAST). It combines stand-ard skills training with intensive case management, based on the assertive community treatment (ACT) model (Stein and Test, 1985). Office-based SST is supplemented and extended by a case manager who helps guide and reinforce appropriate behaviors in the community such as by helping a patient make a doctor’s appointment or learn how to use public transportation. IVAST requires careful assessment of individual skills and needs and the extent to which the living environment is concordant with the patient’s capacity to succeed. The case manager/trainer helps develop skills and/or shape the environment as needed, rather than putting the onus for success on the patient. IVAST has not yet been evaluated empirically but it is a creative approach that warrants careful study.


Cognitive Rehabilitation


Recognition of the importance of neurocognitive deficits has stimulated increasing interest in the prospects for cognitive re-mediation. Results have not been particularly robust but the work has had tremendous heuristic value.


Wykes and colleagues (1999) developed an intervention called cognitive remediation therapy that focuses on execu-tive functioning (e.g., cognitive flexibility, working memory and planning). The approach employs a sophisticated training model that is based on principles of errorless learning, targeted rein-forcement and guided practice on cognitive tasks. Training me-dia consist of a variety of paper and pencil games and neurocog-nitive tests. A preliminary trial yielded improvement on several neuropsychological measures and modest retention of training effects over a 6-month follow-up interval. A limitation of this program is that it employs a highly tailored individual treatment model and demands high levels of therapist skill slowly to shape patient behavior. However, the focus on executive functioning seems much more likely to lead to transferable effects than nar-rowly focused programs designed to strengthen working memory or attention.


An alternative approach to cognitive rehabilitation capitalizes on the ease of standardization and flexibility provided by computer software. Wexler and colleagues (1997) and Bell and colleagues (2001) reported positive results for similar programs that provide self-directed practice on basic attention, memory and reasoning tasks (e.g., visual tracking, pyramids). These programs are limited in that patients find the tasks repetitive and boring, and they do not receive training per se. Patients may become more skilled on the specific tasks but they do not necessarily learn effective strategies that normalize dysfunctional neural circuitry or foster generalization to other situations.


Vocational Rehabilitation


The ability to perform productive work, earn money and achieve a degree of independence is generally regarded as a major factor in self-esteem, quality of life and relationships with significant oth-ers. Yet it is a domain that is particularly difficult for schizophre-nia patients. Rates of competitive employment for persons with schizophrenia are generally less than 25%, and participation in sheltered employment is not much better (Lehman, 1995). There have been numerous hypotheses to explain the poor employment performance of schizophrenia patients, many of which place the onus on symptomatology, especially the sequelae of negative symptoms. Conversely, evidence suggests that employment his-tory, work adjustment and ability to get along or function socially with others are better predictors of employment (Anthony and Jansen, 1984). Social skill and ability to get along with others ap-pear to be critical factors in both securing work (Charisiou et al., 1989) and maintaining employment (Chadsey-Rusch, 1992; Cook et al., 1994; Lehman, 1995).


There are many forms of vocational programs available in the community, including sheltered workshops, job clubs, transitional employment, the Boston University model and programs of job support. With the exception of programs involving job support, there is little evidence that these types of vocational interventions often result in sustained competitive employment among patients with severe mental illness (Lehman, 1995). Such programs, however, appear to provide many patients with structured opportunities for socialization and meaningful daily activity. Such limited goals may be appropriate for certain patients. However, for patients who are interested in competitive employment, it is clear that traditional approaches to psychiatric rehabilitation have proven to be disappointingly ineffective.


Recent evidence from several well-controlled studies suggests that the integrated placement and support (IPS) model of vocational rehabilitation may provide a distinct advantage in increasing rates of competitive employment among patients with severe mental illness (Drake et al., 1999; Lehman et al., 2002). The IPS model emphasizes the integration of vocational and mental health services by having an employment specialist becoming a member of the multidisciplinary clinical management team. The employment specialist helps patients search for real jobs in the community, rather than for placement in sheltered workshops or training programs. After employment is secured, the specialist provides follow-along support in a time-unlimited manner, including intervening with the employer if necessary. A manual has been developed to ensure fidelity of implementation of the approach. However, job retention is a major problem, that requires different strategies than job finding. Given the high priority placed on employment by patients, family members, and the community, improved employment services should be a major focus of research efforts in the future.


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