Psychological Assessment And Treatment Of Persons With Severe Mental disorders

Jeffrey R. Bedell, Jeffrey R. Bedell

• Publisher: Taylor & Francis
• Year: 2013
• ISBN:
  9781134937370
• Edition: 1
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

First published in 1994. Until recently, patients with severe and long-lasting mental disorders were treated primarily through hospitalisation and psychotropic medication. However, now there is a concerted effort to integrate treatment approaches from behavioural and rehabilitation therapies and social skills training.; This book presents an integration of psychological treatment and assessment practices, authored by professionals with established expertise in their subject area. Topics of fundamentally important issues have been selected and divided into three sections: assessment and treatment planning; social and vocational skills development; and group and family therapy in rehabilitation. This volume can be used as a reference handbook, a guide to clinical practice, or a classroom text describing the basic psychological approaches that are effective with patients with severe mental disabilities.

Part One

Assessment and
Treatment Planning

Chapter 1

Assessment and Planning in Psychiatric Rehabilitation

Marianne D. Farkas, William F. O'Brien, +Mikal R. Cohen, and William A. Anthony

Many mental health settings have begun to develop psychiatric rehabilitation programs to enhance or replace existing, more traditional programs (e.g., Allen & Velasco, 1980; Bachrach, 1982; Beard, Propst, & Malamud, 1982). Some are adopting rehabilitation services as a complement to existing services (Anthony, Buell, Sharratt, & Althoff, 1972), while others are moving from no services for persons with severe psychiatric disabilities to a psychiatric rehabilitation approach (Lamb, 1982; Anthony & Liberman, 1986). As psychiatric rehabilitation becomes more widely used as a concept, it becomes necessary to clarify what psychiatric rehabilitation is, and how it differs from other approaches to providing effective services to persons with psychiatric disabilities. This chapter will first clarify the psychiatric rehabilitation approach. Second, it will focus on the unique contributions of the rehabilitation diagnosis and planning process to services for persons with severe psychiatric disability.

Parts of this chapter are adapted, with permission, from: Anthony, W. A., Cohen, M. R., Farkas, M. D. (1990). Psychiatric Rehabilitation. Boston: Boston University. Center for Psychiatric Rehabilitation; and Farkas, M. D., & Anthony, W. A. (1989). Psychiatric Rehabilitation Programs: Putting Theory into Practice. Baltimore: Johns Hopkins University Press.

As the term “psychiatric rehabilitation” has become widely used, misconceptions about the term have also become common. The term “psychiatric” does not refer to psychiatrists as providers, nor does it reflect the notion that psychiatric treatment techniques are used. It refers rather to the population served, persons with psychiatric disabilities. The term “rehabilitation” does not refer to a state agency providing the service, nor does it reflect a unique emphasis on helping people to obtain employment. It does refer to improving functioning in a specific environment. Psychiatric rehabilitation is best defined by its mission or overall purpose, which is to enable persons with psychiatric disabilities to increase their functioning in their chosen environments so that they can be successful and satisfied with the least amount of professional intervention possible (Anthony, 1979; Anthony, Cohen, & Cohen, 1984). Although there are many program settings (e.g., psychosocial clubhouses, supported apartments, supported work) and many techniques (e.g., social skills training, advocacy, job coaching) used in the rehabilitation of persons with psychiatric disability, all of them share a common model and philosophy.

THE REHABILITATION MODEL

The rehabilitation model, as practiced with persons who have severe physical disabilities (e.g., persons with quadriplegia), serves as a conceptual model for the basic goals and treatment process of psychiatric rehabilitation (Anthony, 1980). Despite the obvious differences between difficulties of those with severe psychiatric disabilities and those with physical disabilities, there are similarities as well. Persons with either disability require a wide range of services, exhibit limitations in their role performance, may receive services for a long period of time, and often do not experience complete recovery from their disabilities (Anthony, 1982).

The concepts of impairment, disability, and handicap have been used to describe the domains of rehabilitation (physical or psychiatric) as compared to those of traditional treatment (Wood, 1980; Frey, 1984). Table 1-1 illustrates the rehabilitation model based upon these concepts.

Treatment techniques focus on either eliminating illness or controlling its symptoms. A reduction in pathology or the impairment may not necessarily lead to an improvement in disability. For example, a person's hallucination may be controlled without improving that person's ability to hold a job or return to school—particularly if that person has never held a job or has had great difficulty in remaining in school. As Leitner and Drasgow (1972) pointed out, mental health treatments have focused on minimizing sickness, rather than maximizing functioning and health.

Similarly, improving functioning may not automatically reduce pathology, although such a possibility could occur (Strauss, 1986). Persons may learn to be better students and still have as many psychotic episodes as they always had.

Table 1-1 The Focus of Rehabilitation

	Impairment	Disability	Handicap
Definition	Any loss or abnormality of psychological, physiological, or anatomical function (resulting from underlying pathology)	Any restriction or lack (resulting from an impairment) of the ability to perform an activity in the manner or within the range considered normal	A disadvantage for a given individual (resulting from an impairment or disability) that limits or prevents the fulfillment of a role that is normal (depending on age, sex, social, cultural factors) for that individual.
Example	Hallucinations Ideas of reference Somatic complaints	Lack of conflict resolution skills, planning skills, social skills, daily living skills	Housing Discrimination, Work disincentives
Interventions	Treatments focused on alleviating or reducing pathology (e.g., chemotherapy, behavior modification)	Clinical rehabilitation focused on developing skills and environmental	Societal rehabilitation focused on changing the supports system/society

Note. From Anthony, W. A., Cohen, M. R., & Farkas, M. D. (1990). Psychiatric Rehabilitation. Boston: Boston University, Center for Psychiatric Rehabilitation. Adapted by permission.

They may simply be better able to warn their instructor of an impending episode and develop techniques to protect themselves and their fellow students during the episode. Further, a chronic or severe impairment does not always mean a chronic disability. For example, a person with chronic diabetes may or may not also have a severe disability (Anthony & Liberman, 1986).

The basic philosophy of physical rehabilitation provides direction to the psychiatric rehabilitation process: That is to say, persons with disabilities need skills and supports to function in the living, learning, social, and working environments of their choice. The clinical practice of psychiatric rehabilitation contains two interventions: the development of persons’ skills and the development of environmental supports that enable them to fulfill a chosen role in their preferred living, learning, social, or working settings. The use of these interventions is guided by basic rehabilitation philosophy. Rehabilitation philosophy assumes that changing individuals’ use of critical skills or supports in a specific environment results in their being better able to fulfill the demands of their chosen role. In addition, they become more successful and satisfied in the process. In other words, changing a person's skills and/or environmental supports will benefit both the person (client satisfaction) and society (improved educational and working status) (Anthony, Kennard, O'Brien, & Forbess, 1986; Farkas, Anthony, & Cohen, 1989).

The practice of societal rehabilitation is focused on eliminating barriers in the environment that prevent persons from performing their chosen role (Anthony et al., 1972). The barrier produces a handicap that can prevent those whose impairment has lessened, and whose disability is minimal, from performing their chosen role. Job discrimination, welfare or Medicaid benefit regulations that limit the salary a recipient can earn, and community prejudice are examples of barriers that produce handicaps. Changes in legislation, stigma reduction programs, and rights advocacy programs are examples of societal rehabilitation interventions that can reduce handicaps. Clinical and societal rehabilitation interventions are not mutually exclusive (Stubbins, 1982).

Just as clinical and societal rehabilitation interventions are complementary, so too are rehabilitation and treatment interventions. Treatment and rehabilitation can be complementary approaches because each one is focused on a different target (i.e., impairment vs. disability/handicap), and therefore each one uses different criteria for success. Treatment focuses on the reduction of pathology while rehabilitation focuses on improved role performance in an environment.

THE REHABILITATION PROCESS

The key values of the rehabilitation process emerged from the historical developments that shaped psychiatric rehabilitation as a field. For example, the moral therapy era, the post-World War II development of vocational rehabilitation, and the emergence of psychosocial rehabilitation centers (Beard et al., 1982; Grob, 1983) all contributed to its development (Anthony & Liberman, 1986). These historical trends led to psychiatric rehabilitation's emphasis on pragmatism and the notion of “doing everyday activities”; the importance of people taking on valued roles in the real-world environment (such as work); a belief in the potential productivity of persons with the most severe disabilities; and the primacy of client involvement or ownership of the process.

More recent contributors to the emergence of key psychiatric rehabilitation values include the community mental health center and deinstitutionalization movements. Both the deinstitutionalization movement and the Community Mental Health Centers Act of 1963 underscored the concept that persons could be treated and supported outside hospitals in the natural communities from which they came (i.e., the real-world environment).

The parallel development of the community support initiative (Turner & TenHoor, 1978; Parrish, 1988) strengthened the notion that mental health was in the business of supporting people in the community rather than simply providing paid professionals to treat patients or clients. Persons with disabilities began to understand their right to make choices and to be treated as full citizens, participating within society (Funk, 1987; Ward, 1988).

These historical trends, in summary, resulted in nine key values (Table 1-2). The first value is that of person orientation. The rehabilitation process uses techniques designed to diagnose, plan, and intervene with the person in a holistic manner rather than narrowly focusing on emotional deficits or standard symptoms as the most meaningful aspect of the “case.” The person is viewed as one who has physical, emotional, and intellectual strengths and deficits in relation to the types of housing, employment, and social and educational opportunities that he or she prefers. Because of the primary values of self-determination and involvement, the rehabilitation process focuses on “enabling techniques” designed to empower persons with disabilities to become successful and satisfied in their chosen environment—rather than on techniques that promote compliance with the demands of environments assessed by others to be appropriate for that person's placement. The rehabilitation process helps people to make their own choices about their goals and then gives them the tools they need and want to achieve these goals.

Proponents of rehabilitation value not only the full participation or involvement of the person with disability in the process but also individualization. Individualization is attained when the practitioner is able to tailor interventions to the unique needs of the individual. Practitioners often espouse this value without having a well-defined way to put the value into practice. For example, treatment goals across clients often look alike: “to leave the hospital,” “to control aggressive behavior,” “to take medications appropriately.” When a skill assessment is included in the battery of assessment instruments, it is often an instrument that assesses skills according to a standard list. The list has little to do with clients’ unique situations or the unique demands of their chosen environment. Techniques that allow specific descriptions of individuals in relation to their specific environments, rather than descriptions of functioning in general categories of behaviors, are one important means of addressing individual differences. Further, since clients’ full participation in the rehabilitation process is valued, the process must be flexible in its duration and intensity. Each person has a different rate of progress in overcoming disability. Each person is unique in learning style, preference for intimacy, and tolerance for intense interventions. The rehabilitation process, while clearly systematic, respects these individual differences and paces itself accordingly.

Since the rehabilitation model focuses on overcoming disability (Table 1-1), psychiatric rehabilitation values functioning and techniques that develop functioning rather than those that reduce symptoms or develop insights. Psychiatric rehabilitation methods develop positive behaviors as opposed to controlling negative behavior. Interventions that improve a person's repertoire of skills and environmental supports are the predominant means for increasing functioning.

Table 1-2 Key Psychiatric Rehabilitation Values

Person orientation A focus on the person rather than on the disease; belief in the importance of viewing the person holistically, as one with strengths, and preferences, rather than as a “case” exhibiting symptoms of disease

Self-determination A focus on the person making his or her own decisions

Involvement A focus on the importance of the person being empowered to participate in all aspects of the rehabilitation process

Individualization A focus on respecting the unique differences among persons with psychiatric disabilities; tailoring all aspects of the rehabilitation process to the person's specific needs and wants

Functioning A focus on performance of everyday activities

Environmental specificity A focus on the importance of a person's specific living, learning, working, or social conte...

Table of contents

• Front Cover
• Half Title
• Title Page
• Copyright
• Dedication
• Contents
• Contributors
• Preface
• Introduction
• Part One: Assessment and Treatment Planning
• Part Two: Social and Vocational Skills Development
• Part Three: Group and Family Therapy in Rehabilitation
• Index