Rehabilitation Services

ORGANIZING REHABILITATION SERVICES

The ideal rehabilitation service provides a comprehensive, continuous, coordinated, collaborative and patient-oriented approach. Interventions are linked to individualized needs assessments and to the personal goals of patients, each step negotiated and aiming at end-points that are personally meaningful and desired.

A key aspect of effective rehabilitation is the recognition that peoples’ behavior varies substantially from one situation to another. In general, task performance is more stable than social behavior, and simple skills are more transferable than complex ones. Many of the improvements seen in a narrow rehabilitation setting are transient responses to the particular characteristic of that environment and do not readily transfer or generalize to more complex settings and situations. Therefore, rehabilitation assessment should focus more on an individual’s capacities rather than fixed behaviors and should ideally be carried out across a wide spectrum of settings and conditions, in an attempt to work out what may be achieved under optimal conditions and what problems are likely in suboptimal conditions. People should be prepared for the environments in which they will be expected to function, and in general it is better to rehabilitate in the real situation than in the contrived setting of the hospital clinic.

It is also worth distinguishing long-term targets from short-term goals. The former are often couched in fairly broad terms, whereas the latter are the stepping stones to take the person where they want to go. Short-term goals need to be ‘SMART’ (specific, measurable, achievable, realistic and time-limited) and set in collaboration with the patient, relatives and other relevant people. With these short-term goals in mind specific interventions can then be devised that aim to produce a series of consistent, if modest, achievements backed up by frequent praise, encouragement and support.

It is important to emphasize the individual’s positive capacities and achievements, not only for the good this does self-esteem but also as ‘the most effective antidote to the paternalistic attitudes that develop when psychiatric services try merely to care for long term patients’.

The judicious combination of pharmacological and psychological treatments is, of course, an essential ingredient of rehabilitation practice. These topics are covered in detail elsewhere in this volume. Here we will just outline important approaches to treatments that will reduce impairment and disability and services that address key areas of handicap, housing and employment.

Residential Alternatives

Residential Alternatives

Chronically mentally ill patients in the community require indefinite residential support. 

To meet the variety of needs of chronic mental patients a continuous of residential alternatives is necessary. 

These are:

•    Hospitals

•   Group home: Here several patients live within the same house under24 hours supervision. Here they are teaching skills required to live in the community.

•    Halfway home: Here interpersonal skills and self control are encouraged.

•  Board and care homes: It describes variety of facilities. They are unlocked, patients share rooms, three meals a day are served and minimal staff supervision is provided.

•    Supervised apartment: Patients live in several apartments within the same apartment complex. A staff member who also occupies an apartment in the complex maintains supervision. Usually two patients share an apartment. Focus is on social skill development and independent.

•    Satellite apartment: Here patients are taught to live independently in their own community apartment. Minimal staff monitoring (once monthly) is provided.

COMMUNITY SUPPORT PROGRAMS

COMMUNITY SUPPORT PROGRAMS

There are 10 necessary services to provide by adequate C.S.P

1.   Identify the problems in the hospital and the community and reach out to offer appropriate services.

2.   Provide assistance in applying for entitlements.

3.   Provide crisis stabilization services in the least restrictive setting possible.

4. Provide psychosocial rehabilitation services such as goals-direction, rehabilitation, evaluation, transitional living arrangement and vocational rehabilitation.

5. Provide supportive services of indefinite duration such as living arrangement, work opportunities and age and culturally appropriate daytime and evening activities.

6.   Provide medical and mental health care

7.   Provide back up support to families, friends and community members.

8. Involve concerned members in planning, volunteering and offering housing or work opportunities.

9.   Protect patient’s right, both in the hospital and the community.

10. Provide case-management services to assure continuous availability of appropriate forms of assistance.   

TYPES OF REHABILITATION

TYPES OF REHABILITATION

Rehabilitation programs in India generally classified into 2 groups.

1.         Residential Services 

2.         Non-Residential Service      

In Residential Rehabilitation Programs:

            Hospital Based:        

                        A) Long-term hospital facilities

                        B) Quarter-way home

            Community Based: 

                        A) Half-way home

                        B) Hostels

                        C) Non-governmental charitable agencies

                        D) Foster-care home

In Non-Residential Rehabilitation Programs:

Hospital Based:        

                        A) Day-Care Programs

                        B) Day/Night hospitalization

Community Based:   

                        A) Vocational based rehabilitation

                        B) Community based rehabilitation centers

                        C) Community resources utilization

                        D) Self-Help Group

Pre-requirement for rehabilitation 

1. Diagnosis

2. Assessment of assets and deficits

3. Assessment of prognosis

With improved and more reliable methods of diagnosis, symptoms assessment and functional assessment, the problems and needs of patients requiring psychiatric rehabilitation are becoming better defined.

Assessment of Rehabilitation

The road to rehabilitation must be driven by initial comprehensive assessment and ongoing periodic assessment of the patient’s symptoms and phase of disorders, functional assets and deficits, and personal and environmental resources that can be mobilized for needed services and community support.

Comprehensive evaluation and effective treatment planning require integration of the psychopathological and functional status of the patient is a truly bio-psycho-social approach. Moreover the individuals, family and caregivers must be engaged collaboratively in the assessment and treatment process from the start with identification of the patients desired long-term goals and social roles.

In a functional assessment the clinician work with the patient to identify individual goals, the strength and adoptive skills that facilitate progress and the deficits and excesses that impede goal attainment.

Tools for Functional Assessments

1.   Behavioral Interview: In Functional Assessment through behavioral interviewing the therapist asking the patient to describe the nature and context of behavior deficits excesses and assets.

2.   Direct observation of behavior.

3.   Self Observation: This can be done through a daily diary.

4.   Checklists, Questionnaires and Rating Forms.

5.   Reinforcement Survey: Identification of reinforces that can provide motivation for treatment and maintaining the improved behavior in the community. It helps for negative symptoms.

Family Therapy

Group Interventions -10

Family Therapy

Family therapy is an important component of psychosocial rehabilitation of mentally ill and substance dependence cases. In rehabilitation centres, the family participation in the treatment process of persons affected with mental illness is encouraged. 

Psychiatric social workers play a role or liaison between the client, family and other treatment professionals. 

Initially the interaction with the family are focused on developing a working relationship, eliciting information about the client, illness and the related problems, brief history of family members, understanding about the family dynamics etc.

Family therapy is based on assumptions like:

1. Family member can often be the best to understand the person’s problem.

2. The behavior of one family member has an effect on other members.

3. Family members can often be the part of the solution of the problem.

Given below are some of the roles of family members in the treatment programme and that can be focused during the therapy sessions.

Family members’ fair and detailed understanding about the nature of patients’ illness is crucial in the treatment and recovery. It is found that many of the family do not understand about the illness in detail. Even though many families know about it, they don’t want to accept the facts about the illness and the nature. Many times family says that ‘my son is not a mental patient’ like that. They always connect aggression and violent behavior with mental illness. Out of fear that if they tell the truth about the disorders to the patient they may feel worried or the illness may get aggravated. It is generally accepted that family members who understand the nature of illness can help the patient to get well.

It is important to know that the treatment for mental disorders is long-term process. Long-term medication and constant psychosocial interventions plays important roles in the treatments.

 Realizing misconceptions regarding illness and correcting these misconceptions. Many a families still do not understand the importance of scientific treatment modalities available and efficacy to the same in healing. They still continue to believe that witchcraft, black magic, etc and supernatural powers are responsible for illness. Many a family believes that marriage of a mentally ill person is the solution to his problems. Usually the spouse is the one who is blamed for the partner’s illness. Sometimes family has a higher/over expectation on the treatment that magical changes happen in the patient soon once the treatment starts.

The atmosphere in the home of the patient is also important factor in the patient’s improvement. If there are quarrels in the house, marked dissention of opinion, physical violence or constant nagging, these can adversely affect the recovery of the patient. Similarly, when there is a communication gap or when family members are hypercritical or if they constantly express their displeasure- with the patient (high expressed emotions) this can again affect the patient’s improvement adversely.

Family joint sessions with the client are helpful in confronting the clients who are guarded or denying their illness and related behavioral disturbances. Many times, they develop a better understanding and acceptance of their problems after the joint family sessions. 

Therapist facilitates direct and open communication between the patient and the family during the sessions and thus, helps to settle many conflicts among them. 

Psycho education, supportive techniques, communication skill training, problem solving, are some of the techniques which can be used in helping the family to have a better understanding and way of dealing with the patients. 

Recreation & Music Therapy

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Recreation Therapy

This includes activities based on entertainment, which have clear cut objectives.

Music Therapy

The programme which has therapeutic value with the help of light music. This helps to relax the mind and thereby get away from conflicts and stressors.

Art Therapy

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Art Therapy

Art therapy is a powerful tool that helps one to get in touch with feelings through the creative process. 

By providing a visual explanation as to what is going on inside the mind, art therapy makes the unconscious conscious. 

The art process taps into rich inner resources of material where the experienced art therapist can help, guide and assist in understanding and healing.

Art therapy is used to help patients overcome emotional conflicts and become more self aware. To do this, the art therapist will guide the patients in the use of certain art materials, such as posters or crayons, to express him or her, but clay, paper, or finger paints may also be used, depending on the issue being addressed. These specially selected materials can be used to express what is in patient’s minds before they are able to put into words. Sometimes art is an easier form of expression for patients than verbalizing their pain.

Art therapy can provide a positive feeling of expression within patients as well as allow a physical release of creative energy as work is being created. Creative expressions improve self-esteem, self-awareness, and personal growth and provide a sense of mastery. It can also be less threatening than traditional forms of therapy going deeper through the layers of consciousness to find new meanings that would not ordinarily surface.

If a specific topic is not immediately apparent, the therapist might suggest a topic for expression, such as one’s family or a vivid childhood memory. 

There is a misconception that one needs to be artistic to do art therapy. You absolutely do not need to be an artist.  

The emphasis is on the process and not the product.

Group Work

Group Intervention -7

Group Work

It is teams work in which members are working for a common goal and fixed objectives. 

The aim of group work is to: 

          bring the sense of we-feeling, 

          improve the interaction level, 

         develop the habit of helping each other, 

         acquiring social, interpersonal, communication, leadership and time management skills, 

         develop self-confidence 

         and provide recreation. 

Group Therapy

Group Interventions -6

Group Therapy

Group therapy differs from individual psychotherapy not only in the number of participants, but also on the rationale, methods and the outcome of treatment. 

In group therapy the main therapeutic agent is the group itself. When numerous people interact, the effects are different from those that occur when a pair of individuals (of which one is the therapist) interacts in individual therapy.

Advocates of group therapy have three main contentions:

1.   Therapeutic effects occur more readily with group therapy than individual therapy.

2.   The effects are more lasting.

3.   Social relationships improve more with group therapy.

Types of Group Therapy:

Depending on the characteristics of group and the treatment modality there are various types of group therapy.

1.   Small group and large group therapies: A small group typically consists of five to eight (ideally eight) members belonging to both sexes, between he ages of 20 and 50, with mixed social, economic and occupational background. The clinical problems are also varied. A large group may consist of 20 – 25 members, for e.g. all patients and staff in a treatment unit led by a professional therapist. Various self-help groups (e.g. alcoholics anonymous) are examples of a large group, but differ from the former by the absence of a therapist.

2.   Homogeneous and Heterogeneous groups: The homogeneous group consists of patients with similar problems, e.g. drug addicts, homosexuals, etc. In the heterogeneous group there is a wide assortment of clinical problems.

3.   Open versus Closed groups: In the closed group all members start treatment at the same time and remain together till the group is disbanded. If a member drops out during the treatment, the group members take a decision whether a new patient is to be brought in to replace the lost member. The open group permits members to terminate their treatment at different points and they are replaced by new members.

4. Psychoanalytic versus Group interactive approaches: Psychoanalytic principles are utilized in the former but in group interactive method concepts of group dynamics are applied, that is, processes occurring in a group situation are different from those between an interacting pair of individuals.

During the group meeting time, members decide what they want to talk about. 

Members are encouraged to give feedback to others. Feedback includes expressing your own feelings about what someone says or does. 

Interaction between group members are highly encouraged and provides each person with an opportunity to try out new ways of behaving; it also provides members with an opportunity for learning more about the way they interact with others. 

It is a safe environment in which members work to establish a level of trust that allows them to talk personally and honestly. 

Group members make a commitment to the group and are instructed that the content of the group sessions are confidential. It is not appropriate for group members to disclose events of the group to an outside person.

Why is group therapy helpful?

1.   When people come into a group and interact freely with other group members, they usually recreate those difficulties that brought them to group therapy in the first place. Under the direction of the group therapist, the group is able to give support, offer alternatives and comfort members in such a way that these difficulties become resolved and alternative behaviors are learned.

2.   The group also allows a person to develop new ways of relating to people.

3.   During group therapy, people begin to see that they are not alone and that there is hope and help. It is comforting to hear that other people have a similar difficulty, or have already worked through a problem that deeply disturbs another group member.

4.   Another reason for the success of group therapy is that people feel free to care about each other because of the climate of trust in a group.

Social Therapy

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Social Therapy

It is an organized group living in which integration and continuity of work, play and social activities produce a meaningful total life experiences in which the growth of individual capacity, to enjoy life has maximum opportunity. 


Social therapy can introduce the principles of activity, freedom and responsibility and then help to work towards rehabilitation and the independent life.

Group Interventions - Classification

Group Intervention -4

The group interventions can be broadly classified as:

Social Therapy

Group Therapy

Group Work

Art Therapy

Recreation Therapy

Music Therapy

Family Therapy