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As early as the nineteenth century psychiatrists already suspected that harmful inﬂuences from the social environment might promote the appearance of mental illnesses or have a deleterious eﬀect on their course. In that era, the isolation of the mentally ill in the ‘healthful’ milieu of institutions far removed from their original living environment was thought to be an appropriate means of shielding the patients from the disease-producing inﬂuences of their surroundings. The objective of psychiatric reforms since the mid to late 1950s was to resettle chronically mentally ill persons from large custodial institutions to community settings. The idea behind this was to (re-)integrate patients in their normal living environment as rapidly as possible, because it was thought that their natural social network would make a major supporting contribution to the healing process (Rossler 2001).
This reform has changed the perception of mental illness. Enabling disabled persons to live a normal life in the community caused a shift away from a focus on an illness model toward a model of functional disability (Grove 1994). As such, other outcome measures aside from clinical conditions became relevant. Since then social role functioning including social relationships, work, and leisure, as well as quality of life and the family burden, became of major interest for aﬀected individuals living in the community as well as for the health professionals involved in treatment and care of those persons. Most of the social intervention strategies as applied by health professionals in the community can be integrated within the concept of psychiatric rehabilitation (Rossler 2000).
In current scientiﬁc discourse, environmental and psychosocial factors are often relegated to the status of a single variable of merely peripheral interest, without further speciﬁcation. Biological science has indeed made enormous progress toward an understanding of mental disorders, but it should not be forgotten that research in social sciences also yielded a considerable body of knowledge with respect to the psychosocial and environmental factors that inﬂuence it (Rossler 2001).
The relevance of psychosocial and environmental problems is also reﬂected in the DSM IV and ICD-10. Axis 4 of the DSM (American Psychiatric Association 1994) and codes Z 55–Z 65 and Z 73 of the ICD-10 (WHO 1993) are assigned for reporting psycho- social and environmental problems that may aﬀect the diagnosis, treatment, and prognosis of mental disorders.
1. Target Population Of Social Interventions
Although the majority of the chronically mentally ill have the diagnosis of schizophrenic disorders, other patient groups with psychotic and nonpsychotic disorders are targeted by social interventions. All patients suﬀering from severe mental illness (SMI) now require social interventions. The core group is drawn from patients with:
- persistent psychopathology,
- marked instability characterized by frequent re- lapses, and
- social maladaptation (Royal College of Psychiatrists 1996).
There are other deﬁnitions currently used to characterize the chronically mentally ill, but they all share some common elements, i.e. a diagnosis of mental illness, prolonged duration, and role incapacity.
Furthermore, up to 50 percent of persons with SMI carry dual diagnoses, especially in combination with substance abuse (Cuﬀel 1996). Young adult chronic patients constitute an additional category that is diagnostically more complicated (Schwartz et al. 1983). These patients present complex pictures of symptomatology diﬃcult to categorize within our diagnostic and classiﬁcation systems. Many of them also have a history of suicide attempts. All in all, they represent a patient population that is mostly diﬃcult to treat.
2. Models Of Vulnerability
There are several vulnerability–stress models forming the theoretical basis into which biological and social intervention approaches of psychiatric treatment, rehabilitation, and care can be integrated. These models were developed mainly for persons with schizophrenic disorders, but they apply essentially to all individuals with SMI.
In the ulnerability–stress model it is presumed that socioenvironmental stressors superimposed on an underlying and enduring biological vulnerability lead to abnormalities in central nervous system functioning (Zubin and Spring 1977). In the ulnerability–stress– competence model (Nuechterlein and Dawson 1984), individuals, families, and natural support systems can cope with stressors and have the competence to create a higher threshold for symptomatic illness. In an interacti e–Developmental model (Strauss et al. 1981), the persons aﬀected do not remain in a passive role but actively interact with their environment. They modulate and select the kind of help they get from other people, they choose to comply with the treatment, and they seek or avoid social support and stressful situations.
The interactive–developmental model is the basis for the consumer movement in mental health care. People with mental disorders and their caregivers prefer to see themselves as consumers of mental health services with an active interest in learning about psychiatric disorders and in selecting the respective treatment approaches. Consumerism makes it possible to take up the aﬀected person’s perspective and to consider seriously courses of action relevant to them (Kopelowicz and Liberman 1995).
3. Conceptual Framework Of Social Interventions
The overall philosophy of social interventions in psychiatric disorders comprises two intervention strategies: the ﬁrst strategy is individual-centered and aims at developing the patient’s skill in interacting with a stressful environment. There is no consensus among researchers as to what this individual-centered approach actually does accomplish. Some understand developing patient’s skill as an approach to help disabled persons to compensate for impairments and to function optimally with the deﬁciencies they have. Others assume that diﬀerent forms of individual centered interventions help with recovery from the disorder itself, while the contributing factors to the healing process are not clear (Strauss 1986).
The second strategy is an ecological approach directed toward developing environmental resources to reduce potential stressors. This approach includes social interventions concerning housing and occupation as well as measures to build natural networks, as many chronically mentally ill and disabled persons lose close and stable relationships in the course of the disease. Most disabled persons need a combination of both approaches.
In contrast to acute treatment there are mostly no legal powers to enforce social interventions in long-term care. Thus, the suﬀerer’s autonomy concerning treatment decisions should be respected. Within this frame, therapeutic alliance plays a crucially important role in engaging the aﬀected persons in their own care planning. As such, the therapist should acknowledge that disagreement about the illness between patient and therapist is not always the result of the illness process (Eichenberger and Rossler 2000).
4. The International Classiﬁcation Of Impairments, Disabilities, And Handicaps
The long-term consequences of major mental disorders targeted by social interventions might be described on diﬀerent levels. A useful framework is provided by the international classiﬁcation of impairment, disability, and handicaps (WHO 1980). In addition to acute symptoms, chronically mentally ill patients, in particular individuals with schizophrenia, have impairments in the most basic cognitive processes concerning information input, memory, and abstraction. These cognitive impairments are present even when all symptoms have subsided, and they seem to be enduring markers of a vulnerability to the illness. Persistent and severe impairments lead to disability, i.e., aﬀected persons will be limited in performing certain roles in their social and occupational environment. Finally, handicaps occur when disabilities place the individual at a disadvantage relative to others in society.
On more speciﬁed levels concerning impairments, medication and cognitive training are provided. Eﬀective pharmacotherapy and cognitive training stabilize aﬀected persons so that they are more responsive to learning from their environment. Interventions concerning disability encompass mainly social skills training and family intervention. Furthermore, social interventions emphasize vocational training suitable to the extent of the handicap.
4.1 Reduction Of Impairments
4.1.1 Medication. Even when taken regularly, medication is only able to reduce rather than abolish symptoms, and delay rather than prevent relapse. In addition to that, many of the traditional drugs have adverse eﬀects and can weaken patients’ ability to perform their social roles or can impair their social and vocational functioning. As such, it is not surprising that noncompliance with medication is one of the most serious problems in the long-term care of persons with SMI.
Several treatment strategies have been developed for improving compliance with medication. For patients with cognitive deﬁcits, the complexity of the medication regimen should be reduced (Gaebel 1997). Some patients need to be given the medication by a professional service on a regular basis. Depot medication (i.e., intramuscular injections that release the medication slowly into the bloodstream) might be especially useful for patients with ﬂuctuating motivation or insight. It is also useful to involve families and caregivers in increasing compliance with medication.
Yet, many patients living in the community have to take responsibility for their medication themselves. Training in self-management of medication (Eckman et al. 1990) emphasizes the patient’s autonomy and increases acceptance of and responsibility for treatment. This also includes variation of medication without consultation within certain limits.
4.1.2 Cognitive Training. With respect to cognitive deﬁcits, consistent results emerged from most studies in so far as remediation of speciﬁc deﬁcits through repeated practice or related techniques is successful. But it is not clear if and how recovered cognitive deﬁcits should facilitate the remediation of functional outcome and community functioning. Addressing these limitations, Brenner et al. (1992) developed a comprehensive cognitive training program which they called ‘integrated psychological therapy’ (IPT). IPT comprises ﬁve stages: cognitive diﬀerentiation, social perception, communication skills, interpersonal problem solving, and social skills training. It is presented to groups of ﬁve to seven patients for 30 to 60 minutes two or three times a week. The hierarchically arranged program is aimed at facilitating acquisition and maintenance of more complex skills by remediating cognitive deﬁcits. Findings indicate that IPT reduces psychotic disorganization and improves social, cognitive, and problem-solving skills (Penn and Mueser 1996).
4.2 Remediation Of Disabilities
4.2.1 Skills Training. In recent years, social skills training in psychiatric rehabilitation has become very popular and has been disseminated widely. The most prominent proponent of skills training is Robert Liberman, who has designed systematic and structured skills training since the mid-1970s. Liberman and his colleagues packaged the training in the form of modules which focus on diﬀerent topics such as medication management, symptom management, substance abuse management, basic conversational skills, interpersonal problem solving, friendship and intimacy, recreation and leisure, workplace fundamentals, community (re-)entry, and family involvement. Each module is composed of skill areas. The symptom management module, for example, encompasses skills areas such as identifying warning signs of relapse, developing a relapse prevention plan, coping with persistent symptoms, and avoiding alcohol and drugs. The skills areas are taught in exercises with demonstration videos, role play and problem-solving exercises, and in i o and homework assignments (Liberman 1988).
The results of several controlled studies suggest that disabled individuals can be taught a wide range of social skills. Social and community functioning improve when the trained skills are relevant for the aﬀected person’s daily life, and the environment perceives and reinforces the changed behavior. Unlike medication eﬀects, beneﬁts from skills training occur more slowly. Furthermore, long-term training has to be provided for positive eﬀects (Penn and Mueser 1996).
4.2.2 Family Intervention. As a consequence of deinstitutionalization, the burden of care has fallen increasingly on the relatives of the mentally ill. It is estimated that up to 65 percent of mentally disabled individuals live with their families (Goldmann et al. 1981). This is a task many families do not choose voluntarily. Additionally, not all families are equally capable of giving full support to their disabled member, and may not be willing to replace an insuﬃcient health care system (Johnson 1990). But families also represent support systems which provide natural settings for context-dependent learning important for recovery of functioning (Schooler 1995). As such there has been a growing interest in helping families since the beginnings of care reforms (Strachan 1986).
One area of interest dealt with the expectations of relatives concerning the provision of care. Relatives quite often feel ignored, not taken seriously, and insuﬃciently informed by health professionals. They also may feel that their contribution to care is not appreciated, or that they will be blamed for the patient’s problems. It is certainly not surprising that there is a lot of frustration and resentment among relatives related to the extent of the physical, ﬁnancial, and emotional family burden. As important research has demonstrated a relationship between a negative aﬀective family atmosphere and an unfavorable course of a mental disorder, the need for helping families and patients with family intervention programs became clear.
All family intervention programs include an educational aspect covering basic information on the etiology, treatment, and prognosis of schizophrenia. Although family interventions diﬀer in the treatment focus, all family interventions are organized around the principal goal of providing family members with more information about the disorder and strategies for managing common problems. There are more common features: family interventions are concrete, practical, and focus on everyday coping.
Family intervention programs have produced the most promising results. Family intervention is eﬀective for lowering relapse rate and improving outcome (e.g., social functioning). Possibly, family intervention can reduce family burden. Furthermore, the treatment gains are fairly stable.
However, it is not clear what the eﬀective components of the diﬀerent models are. Additionally, family interventions diﬀer in frequency and length of treatment. There are also no criteria for the minimum amount of treatment necessary.
Finally, it should be noted that most of the familiy interventions were developed in the context of Western societies during deinstitutionalization. Family caregiving might be quite diﬀerent in a diﬀerent cultural context. This refers to other cultures in total as well as to minority groups in Western societies (Guarnaccia 1998).
4.2.3 Reduction Of Handicaps By Vocational Rehabilitation. The beneﬁcial eﬀects of work for mental health have been known for centuries (Harding et al. 1987). Vocational rehabilitation therefore has been a core element of psychiatric reforms since its beginnings.
Vocational rehabilitation is based on the assumption that work not only improves activity, social contacts, etc., but may also promote gains in related areas such as self-esteem and quality of life, as work and employment are a step away from dependency toward integration into society. Enhanced self-esteem in turn improves adherence to long-term care of individuals with impaired insight (McElroy 1987).
Vocational rehabilitation originated in psychiatric institutions, where the lack of activity and stimulation led to apathy and withdrawal among their inpatients. Long before the introduction of medication, occupational and work therapy contributed to sustainable improvements in long-stay inpatients. Today occupational and work therapy are no longer hospital-based, but represent the starting point for a wide variety of rehabilitative techniques teaching vocational skills (Royal College of Psychiatrists College of Occupational Therapists 1992).
Vocational rehabilitation programs in the community provide a series of graded steps to promote job (re-)entry. For less disabled persons, brief and focused techniques are used to teach them how to ﬁnd a job, ﬁll out applications, and conduct employment interviews (Jacobs et al. 1988). In transitional employment a temporary work environment is provided to teach vocational skills that should enable the aﬀected person to move on to competitive employment. But too often the gap between transitional and competitive employment is so large that the mentally disabled individuals remain in a temporary work environment. Sheltered workshops providing prevocational training also quite often prove to be a dead end for disabled persons.
Today, the most promising vocational rehabilitation model is supported employment. In this model, disabled persons are placed in competitive employment as soon as possible and receive all the support needed to maintain their position. Skills are taught in the actual environment, tailored to the job and the individual. If necessary, additional advice is given to the employer. As the course of SMI is unpredictable and job requirements often change, the support provided is neither time-limited nor delivered on a ﬁxed schedule (Wallace 1998). Participation in supported employment programs is followed by an increase in the ability to ﬁnd and keep employment (Baronet and Gerber 1998). But most of the research does not allow evaluation of the impact of vocational rehabilitation programs on nonvocational domains.
Although ﬁndings regarding supported employment are encouraging, many critical issues remain unanswered. Most individuals in supported employment obtain unskilled part-time jobs. Therefore, the high drop-out rate (up to 40%) is not surprising. Since most studies only evaluated short (12–18 months) follow-up periods, the long-term impact remains unclear. At the time of writing, it is not known which individuals beneﬁt from supported employment and which do not (Mueser et al. 1998).
It must be acknowledged that the integration into the labor market by no means depends only on the ability of the persons aﬀected to fulﬁl a work role and on the provision of sophisticated vocational training and support techniques, but also on the willingness of society to integrate its most disabled members.
One result of the diﬃculties of integrating mentally disabled individuals into the common labor market has been the steady growth of cooperatives which operate commercially with disabled and nondisabled staﬀ working together on equal terms and sharing in management. The mental health professionals work in the background providing support and expertise (Grove 1994). Cooperatives serve as a bridge between sheltered workshops and competitive jobs on the common labor market.
4.2.4 Developing Environmental Resources. Eﬀective community psychiatry requires individualized and specialized treatment which has to be embedded in a comprehensive and coordinated system of community services. But even when a variety of services is available, they are poorly linked in many cases, and costly duplication may occur.
While developing community support systems it became obvious that there was a need to coordinate and integrate the services provided as each professional involved concentrates on diﬀerent aspects of the same patient. Therefore, as a key coordinating and integrating mechanism, the concept of case management (CM) originated. CM focuses on all aspects of the physical and social environment. The core elements of CM are the assessment of patient needs, the development of comprehensive service plans for the patients, and arrangement of service delivery (Rossler et al. 1992).
Since the 1980s, a range of diﬀerent models of CM have been developed which exceed the original idea that CM intends mainly to link the patient to needed services, and to coordinate those services. Today most clinical case managers also provide direct services in the patient’s natural environment. This model is called intensive case management (ICM). ICM is diﬃcult to distinguish from assertive community treatment (ACT).
The basic compounds of ACT were developed by Stein and Test in the 1970s (Stein and Test 1980). The original program was designed as a community-based alternative to hospital treatment for persons with severe mental illnesses. A comprehensive range of treatment, rehabilitation, and support services in the community is provided through a multidisciplinary team. ACT is characterized by an assertive outreach approach, i.e., interventions are provided mainly in the natural environment of the disabled individuals (Scott and Dixon 1995). Research on CM and ACT indicates that these models can reduce time in hospital, but have only small or moderate eﬀects on improving symptomatology and social functioning (Mueser et al. 1998).
The goal of social intervention embedded in the broader concept of psychiatric rehabilitation is to help disabled individuals to establish the emotional, social, and intellectual skills needed to live, learn, and work in the community with the least amount of professional support (Anthony 1979). The reﬁnement of all these approaches as described has achieved a level where they should be made readily available for every person with SMI.
But we have to be aware that it is a long way to translate research into practice. In 1992, the National Institute of Mental Health, for example, funded the ‘schizophrenia patient outcome research team’ (PORT) to develop and disseminate recommendations for the treatment of schizophrenia based on existing scientiﬁc evidence. The recommendations address in essence all interventions as presented above (Lehman and Steinwachs 1998). Lehman and colleagues assessed the patterns of usual care for schizophrenic patients and examined the conformance rate with the PORT treatment recommendations. The conformance rate was modest, generally below 50 percent. As such, it is obvious that current care practice has to be improved substantially in the light of the outcome research available (Lehman et al. 1995).
Serious mental illness can devastate the lives of people who suﬀer from it. These persons have a right to be treated according to current knowledge. But mental illnesses are associated with a signiﬁcant amount of stigma, resulting in social isolation and discrimination in housing, education, and employment opportunities. Mentally ill people are even disadvantaged in receiving appropriate treatment and care, so stigma and discrimination further increase the burden on aﬀected persons and their relatives. Yet, social interventions aim at reintegrating the mentally ill into the community and improving their quality of life. For these reasons a responsive and open-minded environment is indispensable. Therefore, translating research into practice always encompasses combating stigma and discrimination of mental illnesses as well (World Psychiatric Association 1999).
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