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Abstract
Pessimistic views about the course and outcome of schizophrenia have been changed There has been a growing consumer movement among people with schizophrenia that has challenged both the traditional perspective on the course of illness and the associated assumptions about the possibility of people with the illness living a productive and satisfying life. This new conception of the illness is supported by long-term studies that suggest that as much as 50% of people with the illness have good outcomes .
Functional deficits associated with the disorder interfere with goal-directed behavior involving one’s career and lifestyle. Thus, a disproportionately large number of people with schizophrenia are chronically unemployed, have not finished their education, do not reside in their own homes, are unmarried, and are estranged from their relatives.
The person labeled schizophrenic carries a powerful stigma to which other people may react with fear and rejection. Because the symptoms of these diseases can affect how a person thinks, feels, behaves, and communicates, the effects of the diseases are often apparent to other people .Many individuals with schizophrenia are devalued and discriminated against because of their mental illness.
It is true that severe mental disorders such as schizophrenia are chronic, not readily reversible, and associated with long-lasting disability the fact that a disease is not reversible or eliminated doesn’t necessarily generate pessimism and resignation. Treatment can suppress the symptoms of severe and chronic medical illnesses. Moreover, rehabilitation can help most of those suffering from chronic medical diseases to regain a fairly normal life. Persons with disabilities stemming from their mental disorders are candidates for psychiatric rehabilitation. Modalities of rehabilitation aim to reverse or compensate for impairments and disabilities, thereby enabling persons saddled with such burdens to function in a more normal Schizophrenia is the most common disorder of persons who utilize psychiatric rehabilitation services.
Schizophrenia remains a complex, dynamic, multi-dimensional, and poorly understood condition .The treatment of schizophrenia requires approaches in many dimensions. Medications are the cornerstone of symptom management but are not themselves sufficient to promote recovery. Rehabilitation strategies involving work, school, and relationship goals are also essential and need to be addressed in creating a plan of care. And Like everyone, individuals living with schizophrenia typically have important goals for themselves in the areas of relationships, work, and living. Developing supports and strategies to help people living with schizophrenia achieve wellness is an active area of psychosocial research today.
The seeds of the recovery vision were started in the aftermath of the era of deinstitutionalization. The failures in the implementation of the policy of deinstitutionalization confronted rehabilitation field with the fact that a person with severe mental illness wants and needs more than just symptom relief.
Recovery definition range from two perspective scientific or professional and consumers or user perspective, they have very different conceptualizations of what the term recovery encompasses. User or consumer movements have reinforced the drive towards empowerment, collaboration, and recognition of human rights. Rehabilitation professionals, on the contrary, have emphasized the need to recognize the value of work and a sense of community in the lives of people with mental illness and the importance of environmental factors in helping people with psychiatric disorders achieve their best functioning.
Many definitions and many views show how different authors think in recovery and show how the concept of recovery is broader and has many angles. One of the most widely used definitions of Recovery defined by Anthony1993 as” a deeply personal, unique process of changing one’s attitudes, values, feelings, goals, skills, and/or roles. It is a way of living a satisfying, hopeful, and contributing life even with limitations caused by illness. Recovery involves the development of new meaning and purpose in one’s life as one grows beyond the catastrophic effects of mental illness.
Recovery from mental illness involves much more than recovery from the illness itself. People with mental illness may have to recover from the stigma they have incorporated into their life, from the iatrogenic effects of treatment settings; from lack of recent opportunities for self-determination, from the negative side effects of unemployment, and from crushed dreams. Recovery is often a complex; time-consuming process
If rehabilitation is the road to recovery, how can the mentally disabled make the journey successful? the overall goal of psychiatric rehabilitation is to ensure that persons with a psychiatric disability have maximum opportunity to recover as normal a life as possible. This means ensuring access to the social, vocational, and recreational responsibilities and privileges of citizens participating in their communities. Rehabilitation connects the personally relevant goals of the mentally ill to services that reduce disability and promote recovery
A widely cited definition of rehabilitation is, “To help persons with psychiatric disabilities to increase their ability to function successfully and to be satisfied in the environments of their choice with the least amount of ongoing professional intervention.
Rehabilitation facilities often are organized in graduated steps that require people to achieve certain abilities within certain period of time. no one including consumers recover in graduated steps. people advance, they regress, they maintain the status quo, they take great leaps forward. Their rehabilitation take a variety of forms depending upon factors such as ;the persons and their experience of life, what his or her specific hopes in the world of work, home, community, or school are?, how accommodating I the environment that they want to go to, how much energy they have, how many resources available to them.
Assessment is the cornerstone of all intervention for persons with psychiatric disabilities. Understanding an individual’s needs is the first step toward identifying the areas that are most important to address, and in evaluating the success of rehabilitation efforts. Therefore, assessment is involved in all aspects of rehabilitation, and skill in assessing individual needs is a prerequisite to effective work with people with psychiatric disabilities.
Substantial evidence indicates that people with schizophrenia can learn a variety of interpersonal and everyday living skills when provided with structured behavioral training that is focused on clearly defined activities, situations, and problems.
Psychosocial skills training procedures are rooted in operant conditioning and social learning theory and represent a highly interactive, structured, systematic, and educational approach to therapy. Instructional methods vary considerably, depending on the content areas of the training program (e.g., conversational vs. symptom management skills), but most interventions emphasize an incremental approach to skills acquisition. Complex target behaviors are broken down into constituent elements, micro behaviors are organized into a hierarchy of responses, and components are introduced to patients in a graded manner. Skills trainers use active teaching methods such as didactic instruction, modeling, behavior rehearsal, coaching of desired responses, corrective feedback, contingent social reinforcement and homework assignments to facilitate the acquisition of new competencies. To counteract schizophrenia patients’ attention, memory, and abstraction impairments, learning material is presented slowly and repetitively in small ”chunks” that contain numerous reviews and positive reinforcement .
Patients are taught to perform component cognitive and behavioral responses sequentially, gradually combining simpler behaviors into more complex reactions. These methods have been applied in both individual and group formats to improve schizophrenia patients ’self-care, social, and independent living skills in hospital, clinic, and residential settings. In addition, behavioral learning principles used in skills training such as shaping, modeling, behavioral rehearsal, prompting, reinforcement, and in vivo homework assignments—have been used effectively in teaching communication and problem-solving skills to families of patients with schizophrenia.
Concerns are frequently expressed that working might worsen the mental health of people with severe mental illness. Several studies of Individual Placement and Support (IPS), however, have found associations between working and better non vocational outcomes. IPS has been found to double the return to work of people with severe mental illness in 6 European countries .There is no evidence that engagement in supported employment leads to increased stress, exacerbation of symptoms, or other negative clinical outcomes .
Supported employment should be offered to any person with schizophrenia who expresses an interest in working. The major components of supported employment are competitive employment in the community, rapid search, for a job rather than prolonged pre-employment preparation, integration of employment and mental health services, an emphasis on client preference and choice regarding jobs, and the availability of ongoing job supports. There is clear evidence that employment outcomes are better when there is greater fidelity to the supported employment model .
Cognitive deficits are routinely evident in schizophrenia, and are of sufficient magnitude to influence functional outcomes in work, social functioning and illness management. Cognitive remediation is an evidenced-based non-pharmacological treatment for the neurocognitive deficits seen in schizophrenia. Narrowly defined, cognitive remediation is a set of cognitive drills or compensatory interventions designed to enhance cognitive functioning, but from the vantage of the psychiatric rehabilitation field, cognitive remediation is a therapy which engages the patient in learning activities that enhance the neurocognitive skills relevant to their chosen recovery goals. Cognitive remediation programs vary in the extent to which they reflect these narrow or broader perspectives but six meta-analytic studies report moderate range effect sizes on cognitive test performance, and daily functioning. Reciprocal interactions between baseline ability level, the type of instructional techniques used, and motivation provide some explanatory power for the heterogeneity in patient response to cognitive remediation.
Persons with schizophrenia who have ongoing contact with their families, including relatives and significant others, should be offered a family intervention that lasts at least 6–9 months. Interventions that last 6–9 months have been found to significantly reduce rates of relapse and re hospitalization. Research has found other benefits for patients and families, such as increased medication adherence, reduced psychiatric symptoms, and reduced levels of perceived stress for patients. Family members have also been found to have lower levels of burden and distress and improved family relationships. Key elements of effective family interventions include illness education, crisis intervention, emotional support,and training in how to cope with illness symptoms and related problems. The selection of a family intervention should be guided by collaborative decision making among the patient, family, and clinician.
Case management, however intensive, is not in itself an effective treatment for the impairments, deficits and handicaps of major mental illness. It is a method for the organization of service delivery which to date has not reliably resulted in the robust clinical gains its early proponents predicted. The future for case management research and practice is the development of services that include specific targeted interventions aimed at improving clinical outcomes whilst maintaining a focus on the most severely ill who are difficult to engage with treatment.
Persons with disabling schizophrenia who are at risk for discontinuation of treatment or for repeated crises require an array of clinical, rehabilitation,and social services to address their needs. Coordination, integration, and continuity of services among providers over time can be substantially enhanced through ACT.
Day care is considered to be an important component of psychiatric services, but the evidence on different forms of day care is not easy to interpret. There are five main forms of day care for adults with severe mental disorders: acute psychiatric day hospital care, transitional psychiatric day hospital care, vocational rehabilitation programs (supported employment and pre-vocational training), day care centers and DROP-in centers
The term “day care” is not easily defined and is best clarified by first defining the functions of day care and then relating these to the various structures to provide them.
Day care for people with severe mental disorders has three main functions: to provide an alternative to inpatient care, shorten its duration and promote recovery and maintenance in the community. These three functions can be provided by day care programs from three different sources: day hospitals, employment services and social care facilities