Vocational Rehabilitation

Professional Intervention -7

Vocational Rehabilitation

1.   Work Skill Assessments

2.   Work Adjustment

3.   Job Skill Training

4.   Sheltered Employment

5.   Transitional Employment

6.   Job Finding

7.   Job Maintenance.

Vocational Rehabilitation comprises as interlocking continuous of assessment and intervention phases. 

Vocational rehabilitation services include elements such as occupational goal settings and functional assessments, assessment of both general and specific work skill, prevocational and vocational training, work hardening sheltered and transitional employment training and support in job search and interviewing skills and supported employment.

Skills Training

Professional Intervention -6

Skills Training

Interventions aimed at correcting deficits in daily living skills such as poor personal hygiene, problems managing the home or dealing with finances are ubiquitous in rehabilitation practice, forming the basis for the daily work of nurses and occupational therapists in most if not all services. 

Many of these interventions involve simple advice, coaching and modeling. 

The more elaborate schemes draw on operant conditioning theory. 

In the most elaborate but now largely defunct approach, programmes were developed in which patients collected tangible rewards (‘tokens’) for performing desired behaviors. These were hugely complex programmes that were very difficult to implement and have proven untenable outside of much specialized settings. Furthermore, the skills acquired in the hospital or clinic often failed to generalize to daily living situations, and the latter had far more complexity than could be managed by a simple contingency-based reward system.

Skills training programme teaches variety of skills, including medication self-management, basic conversation skills, grooming and self-care, job-finding and interpersonal problem solving.

A broad range of interventions are employed, including videotaped demonstrations, role-play, exercises in real situations and homework practice. Numerous clinical trials have shown benefits over standard care in terms of improved conversational skills, assertiveness and medication management. These methods have been successfully employed with patients on acute wards, individuals with residual symptoms and individuals with severe and persistent illness. Not surprisingly, given the focus on specific social behaviors, social skills training have only modest impact on symptoms, relapse and hospitalization.

Cognitive impairment predicts poor rehabilitation outcomes. It is therefore an appealing thought that the remediation of the impairments of memory and executive function commonly seen in people with severe mental illnesses might facilitate skills training and contribute to improve social functioning.

Cognitive remediation seeks to retrain and improve processes of memory, attention and speed of information processing using a variety of ‘exercise’ programmes that were originally developed for neurological rehabilitation (after head injury or stroke, for example). In a study randomized individuals with chronic schizophrenia who had documented cognitive impairment to intensive cognitive remediation or to an ‘intensive occupational therapy’ control condition. Those receiving the intensive cognitive remediation attended for individual, daily, 1 h sessions that focused on executive functioning deficits (cognitive flexibility, working memory and planning). Some improvement in cognitive function was seen with both therapies, but a differential effect in favour of cognitive remediation was found for tests of cognitive flexibility and memory. Social functioning also tended to improve in those whose cognitive flexibility scores improved with treatment.

Negative symptoms, poor social skills and neuropsychological impairments have all been shown to impair performance at work. Medication side-effects can also be problematic. Sedation can be a particular difficulty, although this is less of an issue in contemporary practice, where high-dose regimens are avoided.

Cognitive Behavioral Techniques

Professional Intervention -5

Cognitive Behavioral Techniques

The main aim of CBT is to develop the ability of a person to recognize his / her dysfunctional thoughts do not evoke emotional upset and do not cause changes in behavior and physiological reactions. Dysfunctional thoughts are those thoughts that do not serve any useful purpose. On the contrary they create problems in various areas of life. 

We can divide these thoughts into three types:

1.   Automatic (spontaneous) thoughts.

2.   Distorted thought patterns.

3.   Irrational beliefs or self-defeating beliefs.

Psycho-education is a key element in cognitive therapy.

Cognitive-behavioral interventions have wide applicability for enduring mental illness. For schizophrenia, for example, their main aim is to reduce distress and disability, and to help patients develop an understanding of their illness. Individuals are encouraged to re-evaluate their beliefs through a gradual process of reviewing the evidence and constructing alternative explanations and to identify and manipulate factors that contribute to symptom maintenance. The therapist works collaboratively, taking an active enquiring stance towards the patient’s account of their experiences. Direct confrontation of delusions is avoided, as this has been shown to be counterproductive. Moderately severe thought disorder can be tackled by disentangling the most emotionally relevant themes and helping the individual focus on these using thought-linkage techniques.

The therapist encourages the patient to develop and use a variety of coping strategies, including anxiety management, activity scheduling and attention control, to reduce the occurrence and duration of hallucinations and of distressing experiences of anxiety or suspiciousness.

An impressive number of randomized controlled trials have now been carried out, from which it appears that the approach reduces both positive symptoms and the risk of relapse. 

Behavioral Techniques

Professional Interventions -4

Behavioral Techniques

Methods of Increasing Desirable Behaviors: 

For behavioral contracting, commonly using positive or negative reinforcement for specific behavior with client’s participation and consent. Positive reinforcement involves the addition of something that is equivalent to a reward and a negative reinforcement involves the removal of something that is aversion. Each increases the likelihood of recurrence of any behavior upon which it is contingent. In shaping, behaviors are achieved by reinforcing small steps or approximation towards the final steps. Responses can be initiated by verbal of physical prompting or by modeling in which the therapist demonstrates the required behavior to the subject. In token economy, there is a behavior modification regime that uses reinforcement in the form of tokens, to encourage the learning of positive behavior. The tokens can then be exchanged for special privileges. Reinforcements are initially given for simple responses and thereafter for more complex behaviors.

Methods of Reducing Undesirable Behaviors: 

Aversive techniques, covert sensitization, etc are some of the methods used to reduce the undesirable behaviors.

Methods of Reducing Anxiety and Fear: 

Exposure to feared situations can be carried out slowly or rapidly.  Slow exposure, systematic desensitization, involves including a state of relaxation before a feared stimulus is introduced. Anxiety is minimized by choosing stimuli from hierarchy of cues of increasing difficulty and by interrupting exposure as soon as the subject indicates arousal. The stimulus is reintroduced only when a state of relaxation has been re-established. It is slow, tedious method, which has been largely superseded by rapid exposure. When carried out in vivo it is sometimes called flooding and its use in imagination, at which maximal anxiety levels are evoked, is called implosion.

Relaxation Methods: 

Muscular relaxation methods, breathing techniques, soothing music, etc. Biofeedback consists of providing the subjects with information about the state of his or her physiological functioning.

Methods of Altering Social Behaviors:

Social skills training aims to modify a subject’s social behavior in order to help him or her to overcome these difficulties. Treatment usually involves a programmed course, which is applied to a group of selected subjects.  Behaviors are modeled by the therapist and the group follows this with role play and rehearsal under controlled conditions.  The therapist’s role is to guide, coach and encourage the group.  Group members offer feedback with an initial emphasis upon successful aspects of performance.

Supportive Techniques

Professional Interventions -3

Supportive Techniques

In supportive counseling the counselor uses those counseling methods which stabilize, nurture, motivate and /or guide the clients, enabling them to handle their problems and relationships more effectively within their residual capacities and the available environmental factors.

o   Helps in avoiding / overcoming self or other damaging behavior.

o   Provides activity orientation and help in getting into the structured daily schedule and maintain satisfactory personal hygiene and appearance.

o   Focuses on here-now-issues

o   Helps in gratifying emotional needs.

o   Helps in developing interpersonal relationships.

o   Facilitates intensive work on personal issues which were not discussed during various group interventions.

Supportive techniques are general measures that comfort and guide the client. They are directed at reducing client distress without addressing the psychological and behavioral causes. 




Some of the supportive techniques are briefly described below:
Ventilation: This is supportive technique wherein the client is encouraged to talk.  By talking the client’s emotional distress decreases, and both she/he and the counselor obtain a clearer picture of the problem/situation.

Emotional Catharsis: The client is allowed to let his negative emotions flow freely; as a result, the negative emotions, to a certain extent, are drained out of the system.

Clarification: The confusing / distressing thoughts in the client’s mind are sorted out so that he has a clear understand about the why and how of his feelings and reactions.

Education: Information is provided to the client on the subject of importance to his emotions and behavior.

Guidance: Practical advice is provided to a client during therapy.

Prestige suggestions: Positive attitudes and behaviors of the client are appreciated with a view to enhancing his self-confidence and self-esteem.

Externalization of interest: Client is encouraged to take up an activity that diverts his attention from the area of distress.

Reassurance: Restore the confidence to the Client. Drive away the uneasiness

Persuasion

The different method of Supportive Techniques includes:

1.      Warm, friendly, strong leadership

2.      Gratification of dependence needs

3.      Support in the ultimate development of legitimate independence

4.      Helps in the development of pleasurable sublimation (for eg: hobbies)

5.      Adequate rest and diversion

6.      The removal of excessive external strain if possible.

7.      Hospitalization when indicated

8.      Medication to alternative symptoms

9.      Guidance and advice in dealing with current issues.

Supportive techniques help the patient feel secure, accepted, protected, encouraged and safe and not anxious. 


The verbalization of unexpressed strong emotion may bring considerable relief. 


The reduction of inner tension and anxiety may result from the expression of emotion and its subsequent discussion may lead to insight into a current problems and objectivity in evaluating it. 

Basic Counseling

Professional Interventions -2

Basic Counseling

Counseling Relationship [Rapport]

To develop a relationship with the client, the counselor should have the quality to listen

what the person ventilates as feelings. They might criticize others even the counselor. 

He/she should have patience to listen and give support to them in their present condition. 

If the client feels, he is not the one person who is suffering and somebody is their to listen him, it will be easy to build up a relationship. 

By nature, the people with mental illness is poor in interpersonal relationships, social functioning and time management. So before a psycho-education or insight building sessions, start with a time schedule to focus their social interaction, responsibility, creative thinking and relaxation along with work habit. the client is motivate to think positive and demotivate to be negative always. 

After develop a rapport with the client, can start psycho-educative sessions or CBT  with the help of their detailed case history; that should be from the person who know the client very well. The counselor should not preoccupied at any moment dealing with the client. The details from case history should use as reference only. 

Do family sessions to educate them:

      1. The Client's Nature of Illness

      2. After Rehabilitation .....what should be next

      3. Relapse Prevention

      4. Job Placement

                                ....along with the relationship maintenance [Client & Immediate Family]

Frame out a plan, after the discussion with client and the family, of what should and should not along with the time schedule the client has to follow after discharge. 

Trail basis discharge to know how the plan is working out. 

Job Placement if it is possible to do by the client.

Motivate the family as well as the client to do the follow up for both consultation & counseling. 

Counselor Roles

Resource: Providing at proper time and in proper context and in adequate amount in ways that is understandable to the client.


Support: Support does not mean agreement. Support skills are:
                                                                                           Observation skills, 
                                                                        Listening skills, 
                                                                        Mirroring/reflecting, 
                                                                        Creative confrontation.

Facilitator: This role requires strong counselor-client relationship of trust and understanding. Counselor in this role monitors and supports the change process.

Liaison: Supporting the client in their interface with other agencies, institutions, staff and programmes.

Case Work and Individual Interventions

PROFESSIONAL INTERVENTIONS -1

Case Work and Individual Interventions

One of the important characteristics of psychosocial rehabilitation is that it is ‘individually tailored’ to fit into the needs of each one. 

Individual intervention for individuals with mental illness is based upon a common, shared understanding of the illness between the worker and the client. 

Casework is an important tool in the treatment process of individuals affected with various mental illnesses. It aims at helping an individual client to solve his psychological problems in such a way that he finds himself capable of dealing with these problems at present and in future also.

In rehabilitation centres, casework starts with the admission formalities and taking the detailed case history. There is a prescribed format for case history taking, which help us to understand the picture of the presenting problems, client’s feelings and reactions towards the problem, client’s efforts to solve the problems, family and social conditions, psychological development and the pre-morbid personality of the client.

In casework, the treatment can be either direct or indirect in nature. 

Direct Individual Intervention aims at enhancing the functional competence of the person.

Indirect Treatment (Environmental Manipulation) means to bring change in the social conditions of the client so that he may be relieved from excessive stressors and strains.

PSR Activities

CATEGORIES OF PSYCHOSOCIAL REHABILITATION ACTIVITIES

1.      Medical stabilization

2.      Psycho-education

3.      Day programmes

o   Psychological Therapies

o   Social Therapies

o   Occupational Therapies

o   Recreational Activities

4.      Family Integration

5.      Relapse Prevention

6.      Work Therapy

7.      Placement in jobs

8.      Supportive group therapies for mentally ill and/or their families

Psychiatric rehabilitation

Psychiatric rehabilitation

Psychiatric rehabilitation promotes recovery, full community integration and improved quality of life for persons who have been diagnosed with any mental health condition that seriously impairs their ability to lead meaningful lives. Psychiatric rehabilitation services may include: supported accommodation, supported employment or education, social firms, assertive community (or outreach) teams assisting with social service agencies, medication management, housing, employment, family issues, coping skills and activities of daily living and socializing.

Rehabilitation plan is different for each individual depending on his type of illness, duration, social-cultural factors, severity, family background etc. Team work is on the very important factors in the process of rehabilitation. Team co-operation and coordination is very essential for the success of the rehabilitation programme.

PRINCIPLES OF PSR

PRINCIPLES OF PSYCHO SOCIAL REHABILITATION

1.      Equipping people with skills (social, vocational, educational, and interpersonal).

2.      People have the rights and responsibilities for self-determination.

3.      Services should be provided in as normal environment as possible.

4.      Differential needs and care.

5.      Commitment from staff members.

6.      Care is provided in and intimate environment without professional, authoritative shield and barriers.

7.      Nearly intervention.

8.      Environmental approach.

9.      Unchanging the environment.

10.  No limits on participation.

11.  Work centered process.

12.  There is emphasis on social rather than medical modes of care.

13.  Emphasis is on the client’s strength rather than pathologies.

14.  Emphasis is on the here and now rather than problems from the past.

PSR - GOALS AND OBJECTIVES

Psycho Social Rehabilitation

GOALS AND OBJECTIVES

1.      To help them to involve actively treatment decisions.

2.      To achieve the highest feasible quality of life in the community.

3.      Maximize the residual capacity of the patients.

STRATEGIES

1.      To develop or re-acquire social and instrumental skills.

2.      Modifying the patients’ social, physical and environmental support to compensate for continuing disabilities and handicaps.

CONCEPT AND DEFINITION - PSR

CONCEPT AND DEFINITION

Persons suffering from emotional and mental illness (acute, chronic or sub-acute) are rehabilitated using Psychological, Behavioral, Social, Medical and Occupational methods.

Psychiatric rehabilitation emphasizes continues and indefinite treatment of life long disorders for the maintenance of symptoms control, prevention or reduction of relapses and optimization of performance by the chronically ill patients in social, vocational education and familiar roles with least amount of support necessary for the helping professions.

Psychiatric rehabilitation is defined as the activity of a set of specialist services. Rehabilitation has been defined by the World Health Organization as the application of measures aimed at reducing the impact of disabling and handicapping conditions and enabling disabled people to achieve social integration (World Health Organization, 1980). Implicit in this definition are two components. First, an active process through which a person adapts or acquires the skills needed to mitigate the constraints of disease, and second, an acknowledgement that there may also need to be changes in the environment, including the attitudes of non-disabled people, if optimal social integration is to be achieved.

Psychiatric Rehabilitation, also known as Psychosocial Rehabilitation, is the process of restoration of community functioning and wellbeing of an individual who has a psychiatric disability. It is a process which helps the individuals to find alternatives for hospitalization, emphasizes continues and indefinite treatment of the life long disorder for the maintenance of symptoms, control prevention or reduction of relapses and optimization of performance by the chronically ill patients in social vocational education and familiar roles with least amount of support necessary for the helping professions.

Rehabilitation involves ‘improving the psychiatrically disturbed person’s capabilities and competence’ by bringing about ‘behavioral improvement in their environment of need’. It is helping the individual adapt to their deficits in personal skills by ‘making best use of his residual abilities in order to function in as normal environment as possible’.

Rehabilitation is a helping process where in the client is motivated and encouraged to develop his lost skills and develop on his residual skills so as to become a functional member of the society. Rehabilitation work seeks to effect changes in a person's environment and in a person's ability to deal with their environment, so as to facilitate improvement in symptoms or personal distress. These services often combine pharmacologic treatment, independent living and social skills training, psychological support to clients and their families, housing, vocational rehabilitation, social support and network enhancement, and access to leisure activities.

Psychosocial Rehabilitation (PSR) can be described as consisting of eight main areas of work: Psychiatric (symptom management); Social (relationships, family, boundaries, communications & community integration); Vocational and or Educational (coping skills, motivation); Basic Living Skills (hygiene, meals, safety, planning, chores); Financial (budgets); Community and or Legal (resources); Health and or Medical (maintain consistency of care); and Housing (safe environments).

PSYCHO-SOCIAL TREATMENT

PSYCHO-SOCIAL TREATMENT FOR MENTALLY ILL

Very few services, other than the medical treatment, have been available to persons affected by mental illness. What is required is a programme that helps the person with psychiatric disability learn the physical, emotional, social and intellectual skills needed to live in the community with some support. Thus psychosocial rehabilitation facilitates the opportunity for individuals who are impaired, disabled or handicapped by mental disorder to teach their optimal level of independent functioning in the community. It implies both improving individuals’ competencies and introducing environmental changes in order to create a life at the best quality possible for people who have experienced the mental disorder.

The growing recognition that a large proportion of persons having schizophrenia and mood disorders experience long term disability with persisting symptoms or a relapsing course of illness episodes has given birth to the field of psychiatric rehabilitation. A chronic mental illness is an illness where is the illness have got a long prognosis course. The incidence rate of senior mental disorder in the world is 35 people out of 1 lack in which needs rehabilitation. Out of this 80% of the problems can be dealt with effectively. Psychiatric rehabilitation is a process, which helps the individual to find an alternative for hospitalization.