PSYCHOSOCIAL REHABILITATION OF PSYCHIATRIC PATIENTS WITH SPECIAL REFERENCE TO FAMILY

AND COMMUNITY

DISCUSSANTSNIGDHA SAMANTRAY

MPHIL CLINICAL PSYCHOLOGY

DISCUSSION

The present discussion shall be covered under the following headings:

• Introduction• The need for psychosocial rehabilitation • Efficacy of psychosocial rehabilitation in psychiatric disorders• Efficacy of family based interventions• Efficacy of community based interventions• Evidence based psychosocial rehabilitation• Issues• Psychosocial rehabilitation versus pharmacotherapy• Psychosocial rehabilitation of psychiatric disorders in India• Future direction• conclusion

INTRODUCTION

The presentation has already given us a brief idea about what psychosocial rehabilitation is, its application, models, intervention strategies and its basic framework.

We already know that Psychosocial rehabilitation is a PROCESS initiated by a health or mental Health professional, in collaboration with the patient’s family and community, and supported by policy planners, focused on developing and implementing an individualised programme that seeks to MAXIMISE THE PATIENT’S ASSETS AND MINIMISE DISABILITIES IN THE AREA OF SOCIO-OCCUPATIONAL FUNCTIONING, centring around the philosophy of mobilising and utilising resources available to the community, with the final objective of mainstreaming the client.

The term psychosocial rehabilitation has become so pervasive in the mental health field–indeed, so overused–that it has become necessary to clarify what it is not from what it is.

What psychosocial rehabilitation is not?

Psychosocial rehabilitation is not same as psychiatric treatment: for psychiatric treatment focuses upon Alleviating symptoms and distress with the primary goal of symptom relief. On the other hand psychosocial rehabilitation focuses upon the disability that has been bought by the psychiatric illness with the primary goal of role functioning.

It does not mean that the service must be provided by psychiatrists or that it must use psychiatric treatment methods. “Rehabilitation” reflects the focus of the approach: to improve functioning in a specific environment. Practitioners of psychosocial rehabilitation focus on treating the consequences of the mental illness rather than just the illness per se.

In analyzing the early conceptual differences between treatment and rehabilitation, Louis Leitner and James Drasgow, 1972, pointed out that in general, treatment is directed more toward minimizing illness and rehabilitation more toward maximizing health. Eliminating or suppressing an impairment does not automatically lead to more functional behaviour. Likewise, a decrease in disability does not automatically lead to reductions in impairment, although this could occur.

The table on the next slide indicates how psychosocial rehabilitation is different from other mental health services

(cohen et al, 1988)

SERVICE CATEGORY DESCRIPTION OF THE CONTENT IN THE PROCESS

DESCRIPTION OF THE CONTENT IN THE PROCESS

Treatment Alleviating symptoms and distress Symptom relief

Crisis intervention Controlling and resolving critical or dangerous problems

Personal safety assured

Case management Obtaining the services consumer needs and wants

Services accessed

Rehabilitation Developing consumers’ skills Role functioning

Enrichment Engaging consumers in fulfilling and satisfying activities

Self-development

Rights protection Advocating to uphold one’s rights Equal opportunity

Basic support Providing consumers basic needs to survive

consumer Personal survival assured

Self help Exercising a voice and a choice in one’s life

Empowerment

Wellness/ prevention Promoting healthy lifestyles Health status improved

THE NEED FOR PSYCHOSOCIAL REHABILITATION

• By their very nature, mental illnesses are chronic and relapsing and require a broad range of services, beyond just pharmacotherapy. No treatment of mental disorder can be considered as complete or adequate without giving due consideration to rehabilitation or aftercare services (Channabasavanna, 1987).

• The need for psychosocial rehabilitation arises out of the increasing percentage of mental disorders across the globe.

• Severe mental disorders (SMI) figure among the 10 leading causes of disability and burden in the world (who, 2001).

• An estimate based on extrapolation from household surveys and which excluded homeless people and residents of institutions such as nursing homes, prisons, and long-term care facilities, stated that nearly 4.8 million people suffer worldwide from severe and persistent mental illnesses and 10 million people suffer from serious mental illnesses (IAPRS, 1997).

• A worldwide estimate of the current and future impact of severe mental illnesses has increased dramatically. A new internationally used statistic called the DALY, the “disability-adjusted life year,” is a measure of a year of healthy life lost to a particular disease, either through premature death or disability. The most significant result from measuring disease by DALYs is the new prominence it gives to the negative impact of severe mental illnesses. For example, major depression, typically not mentioned in international health rankings, is currently the fourth leading contributor to DALYs, and is projected to be ranked as the second leading contributor by the year 2020 (Knox, 1996; Karel, 1996).

• Up to 50% of persons with SMI carry a concomitant diagnosis of substance abuse. The so-called young adult chronic patients constitute an additional category that is diagnostically more complicated. These patients present complex patterns of symptomatology difficult to categorize within our diagnostic and classification systems. Many of them also have a history of attempted suicide. All in all they represent an utmost difficult-to-treat patient population.

Case vignette

Simon’s journey into a rehabilitation serviceSimon is in his early 40s. He has had a diagnosis of schizophrenia

for 15 years. He has been hospitalised five times, being compulsorily detained three times. A prominent feature of his illness is his unshakeable conviction that he is under constant surveillance by a government organisation. He believes he is followed wherever he goes and frequently sees people whom he believes to be these agents on the street and in local shops. Partly through fearfulness and partly through apathy, he spends most of his time alone in his flat. He takes no interest in his appearance or hygiene and has serious problems managing the upkeep of his flat, on which he owes a considerable amount of unpaid rent. He has not worked for many years.

The view of some clinicians is that his is a pretty hopeless case. In the course of the long illness, he has received all the usual (and some not so usual) pharmacological and available psychosocial interventions, to apparently little effect. Simon’s view is just as bleak, if not more so. In the past 10 years he has had two consultant psychiatrists, whom he has seen mostly during his spells in hospital, and a string of trainee psychiatrists, seen fleetingly in an out-patient clinic. His main contact has been with a community psychiatric nurse but she moved away just as he was beginning to believe someone might have had his interests at heart. Conversations with mental health staff have mainly concerned medication or been disapproving of his lifestyle. He has picked up the air of hopelessness that surrounds his case, noticing that the enthusiastic promises of new treatments and new referrals (in which he had little faith anyway) have long since dropped away.

Having been out of unemployment for many years, he does not believe that he is employable or, indeed, able to work and cannot see the point of attending a day centre to mingle with strangers or to work without reward. He feels quite powerless to do anything himself and has come to the view that there is little anyone else can do for him.

SIMON IS IN AN URGENT NEED OF PSYCHOSOCIAL REHABILITATION TO GAIN BACK HIS LOST CONFIDENCE, AQUIRE THE DORMANT SKILLS WITHIN HIM ONCE AGAIN AND TO JOIN BACK THE MAIN STREAM IN COMMUNITY.

EFFICACY OF PSYCHOSOCIAL REHABILITATION IN

PSYCHIATRIC PATIENTS

• The outcomes of psychosocial rehabilitation are fairly unique and specific relative to other mental health interventions. Psychiosocial rehabilitation ultimately attempts to improve role Performance or status in people’s living, learning, working, or social environments. While there might be important ancillary outcomes (such as symptom reduction, increased skill performance, changes in service utilisation), the goals of psychiatric rehabilitation services are changes in role performance. (Anthony et al, 2002).

• Oriented toward the practical, psychosocial rehabilitation teaches a patient how to access resources--such as health services and housing availability--and regain independent functioning. It also provides programs of enrichment or self-development, even basic support such as housing and food (McGuire, 2000)

• The Maine-Vermont Longitudinal Comparison Study (Harding, 2000) was undertaken over a period of 32-36 years and is possibly the longest study reported in the literature of the field. It tracked the differences in outcome between people with a psychiatric history in two American states, Vermont and Maine. The major difference in the experience of the two groups was that in one state, Vermont, the participants received a comprehensive model rehabilitation demonstration program, while the Maine patients had received traditional custodial care. In her results Harding reported strong findings that people who had received rehabilitation had both much stronger community and work functioning, as well as substantially reduced symptoms as compared to the ones who had received traditional custodial care.

A Literature review on Clinical, social and cost-benefits of psychiatric rehabilitation Services carried by Common wealth of Pennsylvania, Dept of Public Welfare 1999, analysed fifteen articles published between 1984 and 1998 that described and Evaluated psychosocial programs. Their overall conclusion was that participation in the programs improved ‘functioning’ of the participants. The most commonly reported areas of improved functioning with psychosocial rehabilitation were:

• improved Global Functioning (5 of 6 studies),• increased Employment (10 of 12 studies),• increased Independent Living (7 of 10 studies),• Social/Community Adjustment (4 of 7 studies),• decreased Use of Community Resources (2 of 2 studies),• decreased Hospital Admission Rates (7 of 9 studies),• decreased Time in the Hospital (11 of 13 studies), and• decreased Mental Health or Societal Costs (9 of 9 studies)

• Another parameter indicating the efficacy of psychosocial rehabilitation is its heavy service utilisation. This is supported by studies of heavy service utilization, which have found that 10 to 35 percent of clinical psychiatric populations are heavy users of services and consume 50 to 80 percent of total resources (Kent et al 1995, 1994 and Hardley et al 1992). However, membership in the category of heavy users changes over time; it is not a consistent characteristic of individual patients in a majority of cases and is influenced by social and system factors as well as by the needs of individual patients (Kent et al 1995).

• It is observed that there is a definite limitation to the domains of social functioning, cognitive functioning, and psychopathology in chronic schizophrenia patients who have had no rehabilitation. Vocational rehabilitation significantly improves these limitations, which in turn helps these patients to integrate into the society so as to function efficiently in their roles (Suresh Kumar, 2008).

• Mathai et al.1998 in an unique, but small case control study, tried cognitive re-training of four detoxified male alcoholics and compared it with four controls. At the end of six weeks they found a significant improvement in information processing, memory, and reduction of neuro-psychological deficits. They concluded that neuropsychological rehabilitation was effective in improving cognitive defects of abstinent alcoholics.

Other side of the coinAlthough the literature on the effectiveness of psychosocial

rehabilitation is convincing, a limitation is that the published studies have examined intervention strategies individually rather than in combination. Consequently, we do not know which combinations and amounts of interventions produce optimal effects for which subjects, nor do we know what the additive population effects might be.

For example, individual differences in capacity and responsiveness to currently available treatments have been shown to vary considerably (Kopelowicz et al,1997 and Bell et al, 1996), and individual differences in prior treatment and current medication usually have not been analyzed. In addition, studies of supported employment interventions have shown high dropout rates of 41 to 77 percent within six months, but they have not identified client characteristics that predict success or failure other than prior work history.

EFFICACY OF FAMILY BASED INTERVENTIONS

• Numerous empirical evidences have shown that specific family intervention and inclusion of family in treatment and rehabilitation of chronic mentally ill patients can hasten the good outcomes of the illness and lay of better opportunities to the patients to inculcate the skills important for life functioning (Dixon & Lehman, 1995)

• Evaluations of family based interventions have reported

that by adding them to regimen of medication and customary case management produces substantially better outcomes than the latter two alone (Pilling et al, 2002)

• Involving family in treatment process facilitates better illness management (Kopelowicz et al, 2003).

• The schizophrenia patient outcomes research team (PORT) has developed treatment recommendations for the care of persons with schizophrenia and has categorically pointed that the long term outcome of schizophrenia largely depends on family’s attitude and behaviour towards the patients (Lehman & Steinwachs, 1998)

EFFICACY OF COMMUNITY BASED INTERVENTIONS

• It is noteworthy that community based treatment is well ahead in the term of prognosis of chronically ill patients. Outcome of home community based treatment has same positive aspects like enhanced patients and their family members satisfaction, improvement of symptoms and social adjustment of the patients. Psychosocial rehabilitation is an important component of community support systems for persons with severe and persistent mental illness.

• Some studies on community based rehabilitation (CBR) programs of schizophrenia in day care centres, sheltered work shop and half way homes have shown improvement in recovery for patients with long standing illness in area of residual disabilities of slowness, lack of motivation and social withdrawal because through this way patients get involved in therapeutic process directly and accustomed with the social institutions. They get their lost skill to adopt social situation more quickly than other patient who had been treated in a protected and isolated environment (WHO report 2001).

• Therapeutic strategies like mutual self help group, direct participation in their (patients) own rehabilitation program can provide more favourable outcomes to the patients with long term illness. The relapse rate of alcoholic client’s decrease with level of interpersonal skills of their counsellors which is a follow up study after the 6, 12, 18 and 24 months. It is also suggested that CBR with social skills training and supportive environment give better outcome in mentally ill patients. CBR through primary health program give better outcome and benefit for large number of people through mental health education and counselling and drug distribution (WHO report, 2001).

• Community based rehabilitation (CBR) is a feasible model of rehabilitation for people with schizophrenia even in economically deprived settings, and that outcomes are better, at least for those who are treatment compliant (chatterjee et al, 2003)

EVIDENCE BASED PSYCHOSOCIAL REHABILITATION

• The empirical base of the psychiatric rehabilitation process draws its evidence base from several lines of research. it is the person’s self-determined goals and the presence of the skills and supports necessary to reach those goals, rather than the person’s diagnosis and symptomatology, that relates most strongly to rehabilitation outcomes (Anthony & Farkas, 2009).

• Psychosocial rehabilitation in general and skills training in particular, for both consumers and family members, are intended to promote a range of outcomes (IAPSRS, 1995). These interventions have demonstrated success in symptom reduction, community adjustment, relapse prevention, medication compliance, and reduced use of the hospital and other restrictive settings (Dobson et al, 1995, Smith et al, 1996, Moller et al, 1997 & Conners et al, 1998).

• Cognitive skill remediation has shown promising results in helping patients relearn basic information processing abilities such as attention, concentration, and memory (Cassidy et al, 1996, Corrigen et al, 1996 & Medalia et al, 1998), which are critical to the acquisition of other skills and, in some approaches, are taught together with other skills in an integrated program (Brenner et al, 1994). Cognitive skill remediation has also shown success in directly reducing psychotic symptoms (Corrigan et al, 1996).

• McFarlane and associates, 1992, showed that patients who participated in an intensive case management program that had a vocational and rehabilitation orientation and provided family psychoeducation, had significant improvement in community adaptation compared with patients who received intensive case management alone.

• Reviews and meta-analyses of family psychoeducation studies show consistently strong outcomes for the mentally ill relative (Dixon, 1995 & Mari, 1994), including reduced relapse (Linszen et al, 1997), reduced psychotic symptoms (McFarlane, 1995) and increased self-efficacy for the family member (Soloman et al, 1996).

• Although evidence-based practices are indicated for all persons needing psychiatric rehabilitation, Evidence-based practices are validated by large-scale studies in which means, standard deviations and statistical tests of mean differences between treatment conditions obscure differences between individuals that have profound implications for choice of treatment. Decisions about the type and amount of treatment must be made for each individual, considering their uniqueness, responses to prior treatments and phase of their illness. "One suit does not fit all". Evidence-based treatments should be carefully selected .

ISSUES

Ethical issues

The four guiding ethical principles of medical practice, also referred to psychosocial rehabilitation practice are the following:

• Respect for autonomy of the client: it involves providing the

client the freedom of choice treatment and course of illness after hearing the benefits, risks and costs of all reasonable options.

• Non malfeasance: a Hippocratian code of ethic is an essential rule, preventing the risks of treatment and iatrogenic harm. This principle is often violated with the intention of “good” treatment effect outweighing the “bad” effect.

• Beneficence: providing the form of treatment to the client that would benefit him and would result in meaningful outcome.

• Justice: related to the equal distribution of health care resources, especially to those persons who are in greater need.

Other ethical issues include:• It is unethical if there is a breach of confidentiality e.g.

reporting patient’s “diagnosis” of treatment details to a possible employer and when therapeutic work procedures are videotaped or recorded for education or research purposes, without a previous written informed consent, by the rehabilitation service clients.

• Another important ethical issue is when the rehabilitation staffs challenge the client’s system of cultural values and beliefs, when in the rehabilitation process.

• Another ethical issue arises when the client is not compliant with the programme’s principles and regulations and when aggressive behaviour of a client is directed towards other members and staff, or a sexual misconduct causes problems to others in the programme. It is the staff and the other members of the programme, who will try to “treat” this problematic behaviour and prevent harmful consequences within the limits of Therapeutic Community principles.

• Ethical code violation exists when there is no service internal policy, securing human rights of clients attending the programme.

Legal issues

The following document the so called psychosocial rehabilitation malpractice. They arise when there is:

• Incorrect psychosocial rehabilitation diagnosis of a client, leading to improper service placement.

• Improper work supervision, exposing the client to possible work risks.

• Failure of staff to monitor psychiatric care or prevent adverse psychotropic drug side effects due to lack of intercommunication between mental health care agencies involved in the treatment and rehabilitation of the client.

• Building a psychosocial rehabilitation service programme, with inadequate organization procedures, leading to misdiagnosis, activities with no clear boundaries, improper placement and supervision, are liable for malpractice claims.

• Employment of service personnel with inadequate specialized training could jeopardize the successful rehabilitation outcome and is liable for malpractice claims. However, there is no evidence of malpractice when the client’s poor rehabilitation outcome is not related to negligent rehabilitation procedures.

Issues in special population

Children:

• Children are less able to express themselves in words hence it becomes important to assess their developmental stages appropriately for proper diagnosis and rehabilitation plan. Use of psychopharmacotherapy is less common in children as compared to adults hence their rehabilitation poses a great challenge for therapists. In this instance care, should be provided in a supportive environment with few restrictions and be in units “streamed by phases of illness and developmental stage” (McGorry et al, 2003).

• Confidentiality becomes an issue in child psychosocial rehabilitation as parents always want to know what their children are saying or doing (Madianos,2001)

Geriatric population:

• Cognitive functioning in older adults is the major issue that interferes with the outcome of rehabilitation programme. Increasing age may be associated with reduced brain plasticity and responsiveness to cognitive rehabilitation, perhaps diminishing the impact of a psychological intervention in older people (McGurk & Mueser, 2008)

• There is an urgent need to integrate health promotion, health care, and illness self-management interventions into psychosocial rehabilitative interventions for older adults. Finally, strategies are needed that address the “whole person” as an integrated approach to psychosocial rehabilitation for older adults with SMI, including both the mental and physical health needs (Bartels, 2004).

Rural population:

• Staff turnover in rural and remote regions due to various geographic factors can represent a barrier to the establishment of a consistent service culture, creates an ongoing orientation training requirement and can adversely affect continuity of case management.

• A further issue identified was the inequity of resource distribution that can result when there is a limited response to tenders for non-government services in rural and remote regions.

People from Culturally and Linguistically Diverse Backgrounds

• The sociocultural diversity poses both a problem and a challenge. Psychosocial interventions have to be geared to the individual needs of the patient and their family and keeping in mind their sociocultural background (Kapur, 1992).

• Language barriers also interfere significantly with psychosocial interventions. There is a need for culturally sensitive assessment tools and inventories along with appropriate training to the staff members.

Other issues

• Personnel issues: While programs may refer to themselves as rehabilitation programs, and systems may consider themselves rehabilitation oriented, if the personnel are not trained and experienced in rehabilitation, then rehabilitation will not be practiced. The simple fact is that professional schools of psychology, social work, nursing, psychiatry, occupational therapy, and rehabilitation counseling are not training their students in psychiatric rehabilitation. Effective implementation of psychiatric rehabilitation as part of mental health systems requires that it be taught within professional training programs (Cohen, 1985).

• Program issues: Skilled personnel need to practice in programs that allow them to use their skills. Although the programs may be called “rehabilitation,” they may not be psychiatric rehabilitation programs at all. Policymakers need to know what constitutes a psychiatric rehabilitation program and develop quality assurance mechanisms to ensure that programs identified as such accurately reflect the principles of the field (Anthony, 1992).

• System issues: One of the most significant policy concerns is that the various system functions (planning, funding, management, program development, human resource development, coordination, evaluation, and advocacy) work in concert to implement a psychiatric rehabilitation initiative.

While each system-level function must eventually be compatible with psychiatric rehabilitation, all of these system functions will not begin to change at the same time nor with the same intensity. Policymakers who are initiating a psychiatric rehabilitation approach within their systems should start with those system functions in which personnel seem the most eager to change, as well as those functions that are currently most compatible with the new direction (Anthony,1992)

• Recovery oriented approach: Recovery from mental illness is a highly complex, individualized process. It is assumed that individuals with serious mental illness can recover and have productive work lives, satisfying relationships, and greater meaning in their personal lives (Torrey et al, 2005). There is a dire need for our current mental health system to become more recovery oriented (Anthony, 2000) for the affected individuals to recover in a meaningful way.

• The pervasiveness of mental illness and the heterogeneity of mental illness becomes a major issue for psychosocial rehabilitation (Iyer, 2005).

Issues in Indian context

• In India economic constraint is the major issue. At the governmental level, policy makers have been unable to devote serious attention to the development of rehabilitation services for the chronic mentally ill primarily due to economic constraints (Srinivasa Murthy,1989).

• Studies have shown that in India, families are more tolerant of deviant behaviour and more willing to take care of the ill member (Bhatti et al, 1980; Wig et al, 1987). However, increasing urbanization and lifestyle changes, like the nuclear family system and shrinking social networks, are leading to high distress and burden of caring of the ill (Gopinath & Chaturvedi, 1992).

• Hospital based services are increasingly being made available, however there is an urgent need for more day care centres that can provide the much needed respite for the family as well as make the individual patient feel less stigmatized and more valued (Rao et al, 1988).

• In India, there is a need to emphasize vocational training in day care centres, so that patients can relearn or retrain in marketable skills (Nagaswami et al, 1985), as the patient may often be the sole breadwinner or is at least expected to supplement the family income.

• In India a certain percentage of patients are 'non responders' to treatment and run a downhill course. Provisions have to be made for their long term, residential care. It is essential that such services are not limited to the 'haves', but available to all those who most need it. For this purpose psychosocial rehabilitation has to be made cost effective (Bond, 1984).

• The sociocultural diversity in India poses both a problem and a challenge. Psychosocial interventions have to be geared to the individual needs of the patient and their family and keeping in mind their sociocultural background (Kapur, 1992).

PSYCHOSOCIAL REHABILITATION VERSUSPHARMACOTHERAPY

The debate over psychosocial rehabilitation versus pharmacotherapy is still a controversial subject. Pharmacotherapy is important, there is no doubt about that but in addition to the medical field, rehabilitation has shown significance in treatment. Psychosocial rehabilitation is a holistic approach that places the person, not the illness, at the centre of all interventions (Baron, 2000). Psychosocial Rehabilitation is a healthy alternative or combination to pharmacotherapy. Pharmacotherapy and psychosocial rehabilitation are inseparable; they are two sides of the same coin (Kopelowicz & Liberman, 2003).

Both have different approaches and for better understanding the difference between them is listed below in the next slide in a tabular form.

PHARMACOTHERAPY PSYCHOSOCIAL REHABILITATION

It focuses on the removal of disease symptoms by diagnosis and prescription of drugs.

It focuses on the person with the mental illness as opposed to the diagnosis of the mental illness.

Focuses on symptom relief and stabilisation of current condition.

Focuses on recovery process.

It suggests short-term treatment by medication

long-term treatment focusing onincreasing social status,occupational roles, and independence within the community.

Does not prescribe community integration for treatment

Facilitates for potential supports within the community as an alternative to hospitalization.

PSYCHOSOCIAL REHABILITATION OF PSYCHIATRIC PATIENTS IN INDIA

Current status of psychosocial rehabilitation in India

• Rehabilitation in India is still in its infancy. Although, a rehabilitation sub program aimed at treating and maintaining psychiatric patients in the community, was envisaged in the National Mental Health Program. It could not be implemented due to variety of a reason (Srinivasa Murthy, 2004). At the governmental level, policy makers have been unable to devote serious attention to the development of rehabilitation services for the chronic mentally ill primarily due to economic constraints.

The current status of rehabilitation services of our country as assessed by the national Human Right Commission project report on Quality Assurance in mental health (1999), is as follows:

Structure• Number of psychiatrist, social workers, occupational

therapists and even psychiatric nurses in developing countries can be totally unacceptable by standards elsewhere in the developed world. For instance, India and Australia have roughly same number of qualified psychiatrists while the population of India is about more than 1000 million, while Australia has about 20 million people, Indonesia until recently had 1 occupational therapist for 190 million people.

• About 36% of government mental hospitals have a separate facility for vocational training.

• There are neglected sheltered workshops in the government hospitals.

• Occupational therapy section is present in 63.9% of hospital. However, untrained personnel in an ad hoc carried out these activities. Further in 61% of the centers it was noticed that only a selected number of patients were attending these activities.

• Awareness among staff in psychiatric hospitals regarding the principals of rehabilitation is poor.

Day care centres• Such facilities have started to develop in some hospitals while

7 (19.44%) of the hospital provide day services. The centers providing day care are NIMHANS, Bengaluru, Mental Health Centre, Thiruvananthapuram , KIMH, and Chennai.

• 41.66% of centers reported regular production even though only 36.1% has separate vocational facilities.

Rehabilitation wards• About 8.33 of government psychiatric hospitals have

rehabilitation wards

• There is an interesting experiment being carried at NIMHANS where the nursing staff has been entirely withdrawn from a chronic ward and the patients are entirely in charge of the ward.

Halfway homes• The half way homes concept has taken root in a few states like

Karnatka, Tamil nadu and Kerala. Such facilities are usually managed by NGO’S. 87.8% of the mental health centers don’t have these type of community care facilities in their vicinity.

• There are no separate facilities for occupational therapy and rehabilitation for children in 95% of the hospitals.

Programs• In 53.65% of the hospitals there are no organized programs

for rehabilitation.• Combined programs for male and female are present in

5.55%.• Separate rehabilitation programs for males and females are

present in 33.33%.• Programs only for males in 2.77% and only for female’s

in2.77%.• Most hospitals cater predominantly to psychotics.• 19.44% of the centres ensures employment placement

outside the hospital i.e. NIMHANS.• 25% of mental health centres paid incentives to the patients.

Volunteers and community participation• Only 25 (67.6%) of mental health centres involve volunteers.• The family’s role as a partner in care is not utilized in 95% of the

mental hospitals.

National level programs and policies

• Initiatives from the Ministries of Health and Family Welfare, Government of India

The ministries of health and family welfare have been trying hard to provide social security and welfare to people with psychological and behavioural disorders and disabilities. Some welfare schemes and policies have been implemented by the central government to strengthen the psychosocial rehabilitation in the country. After the independence several legislations and acts have come up to protect the rights and security of chronic mentally ill people and people who have any kind of disability, physical and/or mental .

Initiatives from the Ministry of Social Justice and Empowerment, Government of India

ministry of social justice and empowerment, Govt of India The has taken the following schemes and programmes for the welfare of the people with disability and mental disorders :

• National award for the empowerment of persons with disabilities, persons with any form of physical and psychological disability and mental illness who have done commendable tasks in their respective areas, are felicitated and rewarded.

• Financial assistance to the disabled people willing to set up own entrepreneurs through national handicapped finance and development corporation (NHFDC) in concessional rates.

• Declaration of “national policy for persons with disabilities” • Providing incentives to employers in private sectors for

providing employment to the persons with disabilities.

• District rehabilitation centre (DRC) project (1985) The district rehabilitation centre scheme was implemented to

cater the comprehensive rehabilitation services to the people with disability who stay in remote and rural areas of the country. This programme was planned in collaboration with the national institute of disability and rehabilitation research (NIDRR), Washington, U.S.A. A specific monitoring and evaluating authority namely central administrative and co-ordination unit (CACU) has been set up for looking after the activities of district rehabilitation centre. At present, 11 DRCs have been operational in 10 states in India.

• The rehabilitation council of India (RCI) The RCI was established in the year 1986 to monitor and

supervise the training of personnel related to the rehabilitation of people with physical and psychological disabilities, disorders and impairments.

It is a statutory body which work under the direct supervision of parliament of India and has the twin responsibility of standardising and regulating the training of personnel and professional in the field of rehabilitation and special education. It also promotes research activities to serve the disabled in a better fashion. As per provisions of RCI Act prior approval of RCI is mandatory for all universities, institutions or organisations- government or non-government to start any training course in the field of rehabilitation and special education.

• The National Trust The national trust is a statutory body which works under the

jurisdiction of ministry of social justice and empowerment, Government of India and set up under the National Trust for the welfare of persons with Autism, Cerebral Palsy, Mental Retardation and Multiple Disabilities Act (Act 44in 1999). It initiates and supervises welfare programs for the disabled .

The National Mental Health Programme (NMHP)

The NMHP was taken up by Government of India in the year 1982 to address the mental health related needs of the people as well as to provide rehabilitation and aftercare of the persons with mental and behavioural disorders. It’s a comprehensive mental health programme which not only provides therapeutic and rehabilitative services to the mentally ill persons but also to promote the concept of positive mental health.

Objectives:• Prevention and treatment of mental and neurological disorders

and their associated disabilities.• Use of mental health technology to improve general health

services.• Application of mental health principles in national

development to improve quality of life

• To ensure availability and accessibility of minimum mental health care for all in the foreseeable future, particularly to the most vulnerable and under privileged sections of population.

• To encourage application of mental health knowledge to general health care and social development.

• To promote community participation in mental health services development and to stimulate efforts towards self-help in the community.

Strategies:• Integration of mental health with primary health care.• Provision of tertiary care institutions for treatment of mental

disorders.• Eradicating stigmatisation of mentally ill patients and protecting

their rights through regulatory institutions like the Central Mental Health Authority and State Mental Health Authority

District Mental Health Programme (DMHP)

The DMHP was launched with a community based approach under the NMHP in the year 1996-97.

Objectives:• Training programme for all workers in the mental health team

at the identified nodal institute in the state.• Public education in mental health to increase awareness and

reduce stigma.• Providing OPD and indoor service for early detection and

treatment of mental illness.• Providing valuable data and experience at the level of

community to the state and centre for future planning, improvement in service and research.

Rights of the disabled who are mentally ill • The Mental Health Act, 1987 Under the Mental Health Act, 1987 mentally ill persons are

entitled to the treatment as in patient or outpatient in government hospitals, voluntary discharge, protection and management of property under law, govt. Servant who are mentally ill are entitled to pay, pension, gratuity and other allowance, etc.

• Income Tax Exemptions for persons with disability and families

There are special tax concessions in the Income Tax Act for disabled persons. Section 80 U allows an exception of Rupees 40,000 from the income of the assesses with disability.

To avail of this concession a disability certificate issued by a physician working in a government hospital has to be annexed with the tax assessment form. Section 80 DD allows deductions of Rupees 50,000 to a parent or relative upon whom the disabled is dependent for maintenance, which includes medical treatment of the disabled person

• Exemptions on donations Deductions are allowed to persons making donations to registered

trusts and societies doing work for the handicapped. The relevant sections are 80G and 80GGA. Under Section 80G deduction from Income is allowed at 50 percent of the amount donated to the eligible institution. The amount on which deduction is claimed under the section, however, cannot exceed 10 percent of the gross total income exemptions. This is only in respect of certain specific projects for research, development etc. Deductions in respect of donations may be claimed by all assesses, i.e., individuals, companies etc.

• Exemptions in Custom Duty Certain other special goods imported by a disabled or

disabled person for his personal use are exempt from duty. (Notification No. 20/99 Customs S.No. 278).

• Exemptions in Excise Duty The Central Government exempts all goods manufactured by

an institution which: Is primarily engaged in the rehabilitation of physically or

mentally handicapped persons. Employs primarily, physically or mentally handicapped

persons for its manufacturing activity, is receiving financial assistance from the Govt. of India, Ministry of Social Welfare for such rehabilitation.

• Facilities in travelling Indian railway provides facility of free travelling of mentally ill

person for treatment. Central and state government provides facilities in travelling.

Acts/legislations protecting rights of mentally ill and

disabled people in India

• The persons with Disabilities (Equal Opportunities, Protection of Rights and Full Participation) Act, 1995

• The Mental Health Act, 1987• Rehabilitation Council Act, 1992• The Narcotic Drugs And Psychotropic Substances Act (NDPSA),

1985

Major Rehabilitation centres in India

Some of the major voluntary/ non-governmental organisations/ autonomous organisations in India working in psychiatric and other disability rehabilitation fields are:

• National institute of mental health and neurosciences (NIMHANS),Bangalore, Karnataka

• Deepsikha institute, Ranchi, Jharkhand• Care India• Sevak, Kolkata, West Bengal• Child in need institute (CINI), Kolkata, West Bengal• Samarpan care awareness and rehabilitation centre, Indore, Madhya

Pradesh• Ashadeep, Guwahati, Assam (working for psychosocial rehabilitation

for mentally ill)• Antara, centre for rehabilitation of mentally ill and substance addicted

person, Kolkata, West Bengal• CAIM, Deaddiction and rehabilitation centre, Bangalore.

• St. Joseph rehabilitation centre and relief services, Kolkata, West Bengal; treatment centre for chemically dependent and mentally disturbed.

• Thakur Hari Prashad institute of research and rehabilitation, for mentally handicapped, Andhra Pradesh

• V.D. Indian society for mentally retarded, Malad (W), Mumbai, Maharashtra

• Schizophrenia research foundation (SCARF), Chennai, Tamil Nadu.

• Nav bharat jagriti Kendra, Ranchi and Hazaribagh, Jharkhand• The association for the welfare of persons with a mental

handicap in Maharashtra (A.W.M.H. Male)• Mukta, Mumbai, works for employment and income generation• GRIP- group of rehabilitation, intervention and prevention,

Bandra, Mumbai, Maharashtra• Chetna, Lucknow, Uttar Pradesh

• Richmond foundation, Bangalore, Karnataka• Shraddha (rehabilitation foundation for mentally ill roadside

destitute), Borivali, Mumbai• Param mitra sadan, brother of charity, Kanke, Ranchi (is a half

way home)• Alokendu bodh niketan, Kankurgachhi, Kolkata, West Bengal• National institute of mentally handicapped (NIMH),

Secunderabad, Andhra Pradesh• National institute of rehabilitation training and research

(NIRTAR), Cuttack, Orissa• National institute for empowerment of persons with multiple

disabilities (NIEPMD), Chennai, Tamil Nadu• Central Institute of Psychiatry (CIP)

Ranchi Institute of Neuro-Psychiatry and Allied Sciences (RINPAS) and psychosocial rehabilitation.

• The history of this institute dates back to 1795 A.D. when the Lunatic Asylum was established in Munghyr. Later it was shifted to Patna in 1821 and then to the current location Kanke, Ranchi and was renamed as Indian Mental Hospital (IMH) in 1925. After Independence this hospital came under State Govt. of Bihar in 1958 and the name of IMH was changed to Ranchi Mansik Arogyashala (RMA). On 10th January 1998 the name of RMA was changed to Ranchi Institute of Neuro-Psychiatry & Allied Sciences (RINPAS).

• Currently RINPAS is showing an upward trend in the care of mentally deranged people by providing quality assurance, rehabilitation, community outreach programme, teaching and research activities.

• The institute is running a full fledged occupational therapy and rehabilitation unit offering comprehensive vocational training to in-patients. There are two separate occupational units for male and female section.

• At present both male and female occupational therapy units are equipped with machines and instruments as well as skilled and trained occupational therapy professionals. Both the units have been provided with all sorts of modern gazettes and equipments necessary for providing occupational skills development programme and rehabilitation to the patients’ with long term mental illness.

• A token economy system operates where the patients who work in the OT sections earn tokens according to their level of skill and performance. Patients who just come and sit in O.T. Section are are also given tokens accordingly, to motivate and inculcate in them the habit to work. Patients exchange the tokens earned for snacks and tea from the canteen and rest savings they take home on discharge.

• Currently the institute is running four satellite clinics at Jonha, Khunti, Saraikela Kharsaon and Hazaribagh. The institute is sending medical team comprising of psychiatrists, paramedical staff and students to these outreach community centres every Tuesday of a month. The institute is helped by NGO’s like Nav Bharat Jagriti Kendra & Sanjeevini Gram Trust for these community outreach programs.

FUTURE DIRECTION

• Psychosocial Rehabilitation services should be accessible, equitable and affordable.

• Government should downsize large psychiatric hospitals. More open ward treatment facilities must be created.

• Human resources for psychosocial rehabilitation must be systematically enhanced through both short-term and long-term strategies.

• There should be a national data base of services and human resources available for psychosocial rehabilitation in the country and this should be periodically updated.

• Psychosocial rehabilitation must be converged with the social, education, labour and legal sectors. Translational research must be encouraged in all areas.

• Law review and reform needs to occur periodically. They must emphasise community care, rehabilitation and aftercare.

• Limitations imposed on mentally ill receiving rehabilitation in the area of insurance should be rectified.

• The rehabilitation of vulnerable groups like children, elderly, and women who are subject to domestic violence should receive priority attention.

• There is a need to design outcome studies regarding the effectiveness of rehabilitation program and also it is needed to recognize the interaction between drugs and environmental therapy effects especially in case of ward managements.

• Patients and family members will become more effective as advocates for needed services and partners in treatment, planning and implementation. It is necessary to encourage NGO to start half way homes.

The family’s participation and involvement through regular contact with the half way home staff should be encouraged to make community adjustment easier.

• There is an urgent need for more day care centers that can provide the much-needed respite for the family as well as make the individual patient feel less stigmatized and more valued.

CONCLUSION

Psychosocial Rehabilitation exhibits principles of hope, change and recovery for Persons with severe and persistent mental illness. Effective mental health service providers should facilitate change through the recovery-oriented theory. Recovery is individualized and person centred, placing the person at the core of all interventions with the goal of rehabilitating and re-integrating the individual to active community life. For successful rehabilitation, co-operation and collaboration of health care personnel, patients and their family members, opinion leaders, policy makers and various agencies are indispensable. Then only we can hopefully address the rehabilitation of psychiatric patients in a more meaningful manner and make them more meaningful citizens of our country.

For a successful outcome it is very essential to catch the hint for psychosocial rehabilitation at an early stage.

How many times it thundered before Franklin took the hint! How many apples fell on Newton’s head before he took the hint! Nature is always hinting at us. It hints over and over again. And suddenly we take the hint. —Robert Frost

WHERE THERE IS NO HOPE THERE IS NO

RECOVERY

THANK YOU