Nurs Clin N Am 38 (2003) 151–160

Psychosocial rehabilitation
Deborah Antai-Otong, MS, RN, CNS, NP, CS, FAAN
Employee Support Program, Mental Health Outpatient Clinic, VA North Texas
Health Care System, 4500 South Lancaster Road, Dallas, TX 75216

Psychosocial rehabilitation is a model that provides a holistic, compre-

hensive, and seamless plan of care for patients with severe and persistent
mental illnesses. Major components of psychosocial rehabilitation include
interventions that facilitate symptom management, facilitate social skills
training, and improve cognitive performance. The goal of psychosocial
rehabilitation has evolved from medication compliance and reduced hos-
pitalization to helping the patient attain independence, employment, mean-
ingful interpersonal relationships, and an improved quality of life [1].
Ultimately, these goals facilitate the highest level of functioning in all
spheres, self-efficacy, and well-being for patients with severe and persistent
mental disorders. By attaining these goals, patients with schizophrenia
and other severe and persistent mental disorders can experience minimal
interference from symptoms and neurocognitive deficits. Predictably the
success of these programs is enhanced by involvement of families and sig-
nificant others [2–4]. Achieving these goals requires integration by the
interdisciplinary team model that involves the delivery of comprehensive,
coordinated, and seamless services that are consumer-friendly and accessible
to the patient, caregivers, and cultural and social context.
Psychiatric nurses play pivotal roles in the efficacy of evidence-based
psychosocial rehabilitation and are important members of interdisciplinary
teams that provide holistic health care services ranging from symptom
management to facilitating vocational rehabilitation. Psychiatric nurses,
similar to other team members, patients, and caregivers, are also responsible
for the planning and implementation of these services. This article focuses
on psychosocial rehabilitation as an evidence-based practice model for the
treatment of schizophrenia and other severe and persistent mental dis-
orders. The role of the psychiatric nurse in the planning and implementation
of interdisciplinary interventions that promote symptom management,

E-mail address: Deborah.antai-otong@med.va.gov

0029-6465/03/$ - see front matter Ó 2003, Elsevier Science (USA). All rights reserved.
doi:10.1016/S0029-6465(02)00068-3
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self-efficacy, assertive community treatment, psychoeducation, and voca-

tional rehabilitation also is discussed.

Major components of psychosocial rehabilitation

Studies underscore the significance of symptom management, social skills
building, and strengthening cognitive functioning to prepare patients for
rehabilitation services [3,4]. Pharmacologic interventions are necessary to
reduce or extinguish symptoms and provide opportunities for the patient to
develop and attain social and mental health rehabilitation and an optimal
level of functioning. Psychiatric nurses are responsible for understanding the
basis of medication, monitoring for desired responses and acute and chronic
adverse drug reactions, and psychoeducation concerning mental illness and
treatment options. Regardless of the patient’s condition, it is imperative for
the nurse to identify symptoms and treatment options and to integrate the
patient’s individual and cultural needs into treatment planning.

Symptom management
The initial phase of psychosocial rehabilitation begins during the acute
phase, at which time the primary goal is controlling and stabilizing symp-
toms of severe mental disorders, often with pharmacologic interventions.
Depending on the nature of the symptoms, various medications are used.
The mainstay treatment of serious and chronic mental illness is pharma-
cotherapy [5,6]. Predictably the patient’s presenting symptoms determine
the exact medication. As previously mentioned, antipsychotic or neuro-
leptic agents are the primary medications of acute and chronic psychosis.
Novel neuroleptic agents have been shown to have clinical efficacy in
the treatment of treatment-resistant psychosis, although they have dose-
related side effects similar to conventional agents with the exception of clo-
zapine. Antidepressants and anxiolytic or antianxiety medications are
primary medications for depressive and anxiety symptoms. Although novel
antipsychotic agents are preferred for maintenance treatment of psychotic
disorders, conventional agents are likely to be used to manage acute
symptoms, particularly when a parenteral route is necessary. (See also the
Antai-Otong and Jensen articles in this issue concerning nursing implica-
tions for the management of acute psychosis and neuroleptic-induced side
effects.)
Because of notable advantages of novel pharmacologic agents, patients
with serious and chronic mental illnesses are more likely to reach an opti-
mal level of function when this approach is integrated with psycho-
social interventions. Of particular importance to medication management is
family and patient psychoeducation. Patients with schizophrenia may enter
treatment with acute psychosis. Efforts to assess the underlying cause of
the acute symptoms must involve making a differential diagnosis. Nurses
 D. Antai-Otong / Nurs Clin N Am 38 (2003) 151–160 153

often are involved and gather crucial data, including assessing vital signs,
drug toxicology screens, and chemistry profiles; performing a mental
status examination; and obtaining an extensive substance abuse history
that provides information about symptoms, duration, past treatment, and
current medication. Cultural considerations must be an integral aspect of
the assessment process to reduce misdiagnosis and ultimately inappropri-
ate treatment planning. Cultural considerations also must include family
involvement, patient preferences, and the role of religion and other spiritual
components [7,8]. When a definitive diagnosis is established, treatment of
acute psychosis involves parenteral or oral administration of a neuroleptic,
such as haloperidol (Haldol), and a benzodiazepine, such as lorazepam
(Ativan). Another example is acute mania in a patient with a history of
bipolar I disorder. Treatment is often similar for these two patients. In
contrast, a patient experiencing acute anxiety may complain of chest pain,
difficulty breathing, and odd physical sensations and require a dose of
a benzodiazepine to reduce anxiety. Regardless of the presentation, these
patients require immediate attention and psychotherapeutic and pharma-
cologic interventions to move from the acute phase to rehabilitation.
Acute management of the patient’s symptoms may involve acute and
short-term hospitalization to stabilize medical and psychiatric symptoms
or referral to a day hospital program or individual psychotherapist. Of
particular importance to the nurse during this phase is making an accurate
diagnosis and initiating appropriate interventions and referrals. Community
referrals must involve family therapy and involvement and a comprehensive,
seamless plan of care. The efficacy of these interventions is well documented
and shows that they are cost-effective and provide quality mental health care
that prevents psychotic relapses and rehospitalization [2,9–11].

Self-efficacy and management of illness

As patients transition from the acute symptom management stage,
psychiatric nurses must monitor their response to treatment and provide
opportunities for success. As the nurse administers or prescribes neuroleptic
agents, it is imperative to educate the patient and significant others about
schizophrenia or other serious mental disorders, reasons for medications,
and potential side effects. This process facilitates insight into the patient’s
symptoms and illness and promotes self-efficacy as the patient moves
through the treatment continuum. Understandably, psychiatric rehabilita-
tion evolves during the acute stages of a psychiatric disorder and continues
throughout the life span. Mental health services must parallel stages of
symptoms across the treatment continuum and meet the patient’s holistic
needs and foster competence and management of illness.
Self-management of illness often requires structured interventions that
promote self-efficacy, independence, employment, quality interpersonal
relationships, and a good quality of life. Self-efficacy and management of
154 D. Antai-Otong / Nurs Clin N Am 38 (2003) 151–160

symptoms are crucial to moving from inpatient to community-based

settings. Throughout the course of treatment, patient and family needs
must be assessed thoroughly so that they can guide treatment planning
and facilitate competence in managing symptoms and responsibility for
treatment outcomes. Dhillon and Dollieslager [3] delineated five core ob-
jectives of psychosocial rehabilitation as follows:
 Assess the patient’s personal goals in life, including self-efficacy,
autonomy, and quality of time with friends and family, and how they
can be facilitated by inpatient modalities and symptom stabilization
 Provide health education to the patient and significant others
concerning the nature of the mental illness and how medications may
be useful in restoring self-control
 Educate the patient about medication and treatment adverse effects and
the importance of self-monitoring and collaborating with the nurse or
other health care provider concerning medication and its effect
 Embrace the patient’s cultural needs and collaborate with the family or
other community-based resources
 Engage the patient in decision making regarding appropriate aftercare
plans for residential and treatment needs after discharge
An avenue that integrates these principles is intensive case management.

Psychotherapeutic interventions
Intensive case management
Historically, case management did not meet the needs of patients with
schizophrenia because patients were referred to a single case manager
who functioned as a broker of services, rather than being assigned to a
community treatment team. Case management refers to the coordination,
integration, and allocation of holistic care within a spectrum of resources.
This concept has evolved over the years in an effort to overcome deficiencies
in community-based mental health care and correct fragmented care and
lack of continuity of care.
The traditional case management model was unsuccessful in reduc-
ing hospitalization with little evidence of improving mental health social
functioning or quality of life. This older model had high caseloads and
used an individual versus a team approach to access patient resources,
emphasizing community team outreach rather than referring the patient to
other providers. This may have been related to the model’s failure to reflect
the relevance of cognitive and social skills necessary to follow-up with
appointments and get one’s needs met. Combined, these factors placed the
patient at risk of relapse.
A contemporary approach to intensive case management is the assertive
community treatment (ACT) program [3]. With this approach, the patient
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is assigned to an interdisciplinary community team that includes a case

manager, nurse, and other providers. ACT team members have lower
caseloads than their predecessors. There is high staff-to-patient ratio that
delivers services when and where needed by the patient, 24 hours a day,
7 days a week [12–15].
The primary goal of intensive case management is prevention of
rehospitalization. Reducing rehospitalization in high-risk patients through
the provision of comprehensive integrated community services is cost-ef-
fective and a necessary component of this approach. Most researchers
looking for cost-effective mental health services for the seriously mentally
ill have found that the ACT model program consistently shows reduced
hospitalization and stability in the community and housing [2,6,11,14]. The
case manager role in the ACT program is especially suitable for the nurse
because nurses traditionally have been health care brokers, providers
of mental health care, and active members of the interdisciplinary team.
Ideally, as a case manager, the nurse oversees and integrates seamless ho-
listic treatment planning and facilitates patient access to appropriate com-
munity services [11,16].
An integral aspect of an intensive case management program is social
skills training and vocational rehabilitation. Implementation of these com-
ponents further strengthens rehabilitation, promotes recovery, and a higher
level of functioning.

Social skills training and rehabilitation

Intensive case management programs such as ACT offer a wealth of
opportunities to provide effective and individualized mental health services
to patients with serious mental illness. Another aspect of integrated services
using this model is social skills training. Psychiatric nurses involved in social
skills training must do a comprehensive biopsychosocial assessment and
determine the patient’s mental and physical health and readiness for train-
ing and rehabilitation. The patient’s social and functional status often paral-
lels symptom management and cognition [14]. Studies show that cognitive
capabilities and community functioning are strongly related. Medications,
specifically novel antipsychotics or neuroleptics, seem to be the mediator
between social functioning and cognitive performance [17,18]. Social skills
training refers to necessary competencies that allow for optimal social per-
formance. Social skills training employs learning theory principles to fa-
cilitate optimal social and community functioning, including activities
of daily living, employment, leisure, and interpersonal relationships. The
premise of social skills training is that it affords the patient opportunities to
reach an optimal level of functioning and self-efficacy and reduce relapse.
Bellack and Mueser [19] described the following models of social skills
training: basic, social problem solving, and cognitive remediation. The
basic model involves corrective learning, practiced through various means,
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including role playing. If the patient lacks assertive communication skills,

the nurse can teach these skills and enhance them through role playing
and constructive feedback. The social problem-solving model focuses on
enhancing impairments in information processing assumed to result in
social skills impairments. Major foci for the social problem-solving model
include requiring changes in medication and symptom management, leisure,
communication skills, and self-care. Each domain is taught in a module
format with the goal of correcting receptive, processing, and transmitting
skills deficits. Nursing interventions that promote these changes include
providing examples of potential situations and asking the patient to think of
with possible solutions. When these solutions are presented, the nurse can
offer feedback and options for improving communication and problem-
solving skills. These solutions also may include side effects and possible
ways to resolve them, including whether to call the provider concerning their
effects. The premise underlying the cognitive remediation model includes
cognitive deficits in attention or planning and helping the patient move from
an individual approach to a community approach [20]. Nursing interven-
tions involving cognitive remediation may include asking questions about
upcoming situations regarding employment, conflict management, or need
for medication changes. By offering these scenarios and providing basic
communications tools to resolve them, the nurse enhances the patient’s
problem-solving, stress-management, and conflict-resolution skills, resulting
in higher confidence and self-esteem.

Psychoeducation and family therapy

The global burden of serious mental illnesses, such as schizophrenia, is
profound and often extends to the family, culture, and community. Efforts
to strengthen family and community-based resources are crucial to suc-
cessful reintegration into the community and prevention of rehospitaliza-
tion. The ACT program has been mentioned as one aspect of this process.
Another aspect of the ACT program requires family or significant other
involvement. Because of the intimate role that nurses play in mental health
treatment planning, they must play key roles in identifying family, patient,
cultural, and community stressors and strengths and collaborate with other
members of the treatment team to support and empower family coping
skills. Family stress often manifests as expressed emotion or an index of
criticism, overinvolvement, and hostility. The expressed emotion research
shows that when levels of emotion are reduced, so are psychotic relapses
[17].
Research consistently shows that the vulnerability-stress model of
schizophrenia suggests that patients with mental illnesses are likely to
relapse and return to the hospital when community resources are inadequate
[21]. Because schizophrenia and other severe and persistent mental disorders
are costly and labor intensive, efforts to strengthen the family and
 D. Antai-Otong / Nurs Clin N Am 38 (2003) 151–160 157

community resources during these times are crucial to the mental health of
the patient and community. Multifamily groups enable members to express
their feelings and concerns about living with someone with a chronic men-
tal disorder and promote self-management of illness. Nursing implications
from this premise include assessing family stressors, identifying family
strengths, and providing health education that enables family members to
understand their loved one’s symptoms and ways to manage them and
to facilitate health coping skills. Working with other team members
and community agencies provides numerous opportunities for the patient
and family to strengthen their coping skills and develop successful treatment
recovery and outcome. Psychiatric nurses must work with the patient and
family and formulate and implement a comprehensive intervention pro-
gram that eventually includes reducing dosages of antipsychotic medica-
tion, relying on novel medications to control symptoms, and implementing
psychosocial interventions that integrate specific needs of the patient and
family.
There are many psychosocial family interventions, including those that
begin on inpatient units and continue on an outpatient basis. One program
has been established for first-episode psychosis and has a 1-year, phase-
specific, community-oriented treatment mode [22]. Researchers using this
model submit that poor outcomes are linked to delayed treatment, lack of
integration, and lack of medical and psychosocial interventions [22,23].
Support for this new approach that involves early interventions, particularly
for first-episode schizophrenia, is showing great promise because it provides
treatment on a continuum that begins during the acute period and continues
into the community [22,23]. Major goals of this model include bolstering the
patient’s activities of daily living skills, improving communication skills, and
providing mutual support during the transitional phase of recovery from
acute psychosis. This program is based on a structured 8-week model that
reflects various themes, including self-identity, health education concerning
the definition of psychosis, peer pressure and substance-related disorders,
family and social interactions and medications, stigma, social skills and
recovery, return to work or school, and warning signs of relapse. When
patients complete this introductory phase, cognitive-oriented skills training
is introduced and implemented over a 10-week period.
As with most models, family intervention is an integral part of this
training; this particular model for first-episode psychosis is based on
Anderson and colleagues’ [24] psychoeducation and management teaching
model, modified to address the specific needs of younger first-episode
patients. A period of engagement, initial crisis resolution, social support,
and a series of psychoeducation workshops strengthen the patient and
family’s coping skills and assist them in managing various stressors
associated with having a serious and chronic mental disorder. This psy-
choeducation model was designed for first-episode psychosis, but major com-
ponents can be modified to meet the needs of most patients experiencing
158 D. Antai-Otong / Nurs Clin N Am 38 (2003) 151–160

a serious and chronic mental illness. Psychiatric nurses play pivotal roles
in working with the patient with serious mental disorders from the acute
stage to the transition to family and community-based settings. Throughout
the treatment process, patients must be empowered and encouraged to take
responsibility for their recovery. Through self-efficacy activities, family in-
volvement, and psychoeducation, the patient gains a sense of indepen-
dence and confidence to seek and form quality interpersonal relationships,
initially with the nurse and later through family interactions. As these
skills evolve, so does confidence that propels the patient to participate
in workshops and other community employment. Nurses must offer op-
portunities for the patient and family to identify and express concerns as
consumers and promote a good quality of life.

Supported employment
Ultimately, psychosocial rehabilitation prepares the patient for sup-
ported employment [5,26]. These programs offer incentives for patients with
severe mental disorders to increase their autonomy as recovery or re-
habilitation progresses. Major goals of these programs include assisting
individuals with disabilities, such as chronic mental illness, as much as
possible in the competitive labor market that parallels their strengths, pre-
ferences, priorities, and abilities [25]. In addition to benefiting the pa-
tient, supported employment adds to the workforce and community. Nurse
case managers also provide opportunities to participate in supportive psy-
chotherapy and problem solving that assist the patient in daily prob-
lems and coping with his or her illness. Through structured or supervised
workshops and work programs, patients gain a sense of self-worth and
independence and develop interpersonal relationships that involve family
members and peers. Research studies indicate that a major barrier to
supported employment is access despite their increasing use. It is impera-
tive for nurses to stress the importance of self-management and deal with
substance-related disorders.
As the patient moves through the recovery process and treatment plan
continuum, his or her ability to feel confidence and control his or her
symptoms often is guided by available resources, absence of substance-
related disorders, and motivation to stay in treatment. Psychosocial
rehabilitation is one aspect that fosters successful treatment outcomes,
independence, self-management of illness, meaningful relationships, and
a good quality of life. Psychiatric nurses play pivotal roles in helping the
patient attain these goals.

Summary
One example of a psychosocial rehabilitation model uses an intensive case
management approach. This approach offers an interdisciplinary model that
 D. Antai-Otong / Nurs Clin N Am 38 (2003) 151–160 159

integrates pharmacotherapy, social skills training, and family involvement.

This evidence-based plan of care is cost-effective and offers psychiatric
nurses opportunities to facilitate symptom management, facilitate self-
efficacy, and improve communication and social skills. Ultimately, nursing
interventions promote a higher level of functioning and quality of life.
Nurses in diverse practice settings must be willing to plan and implement
innovative treatment models that provide seamless mental health care across
the treatment continuum.

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