PSYCHIATRIC REHABILITATION 1

PSYCHIATRIC REHABILITATION –
AN INTRODUCTION
*
Santosh Kumar Chaturvedi
Rehabilitation is an important component of tertiary care of
illnesses and diseases. It has gained importance in mental health as
a key element of care for persons with mental illness. Professionals
view psychiatric rehabilitation in varied ways, as a therapy or
therapeutic method of intervention, an approach, an outcome variable,
a philosophy, a model of care, lifestyle / life skills progamme, a goal,
and even a catchphrase. There is also a debate on whether the
appropriate term should be psychiatric rehabilitation, psychosocial
rehabilitation, cognitive rehabilitation, or recovery oriented service or
practice. To resolve this, the World Health Organisation and World
Association of Psychiatric Rehabilitation released a consensus
statement about psychosocial rehabilitation in 1996.
‘Psychosocial rehabilitation [PSR] is a process that facilitates
the opportunity for individuals - who are impaired, disabled or
handicapped by a mental disorder - to reach 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 of the best quality possible for people who have
experienced a mental disorder, or who have an impairment of their
mental capacity which produces a certain level of disability. PSR
aims to provide the optimal level of functioning of individuals and
societies, and the minimization of disabilities and handicaps, stressing
individuals’ choices on how to live successfully in the community.’
[Psychosocial Rehabilitation - Consensus statement, Division of Mental
Health, WHO, Geneva, 1996]
The consensus statement further describes that ‘PSR is complex
and ambitious because it encompasses many different sectors and
levels, from mental hospitals to homes and work settings. Hence it
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encompasses society as a whole. Nonetheless, it is an essential and People with mental illnesses are among the most stigmatized and
integral part of the total management of persons disabled by mental socially rejected. The stigma of mental illness is often experienced
disorders. In consequence, the bodies involved in PSR are also varied, as more painful, long lasting, and difficult to overcome than the illness
e.g. consumers, professionals, families, employers, managers and itself. Stigma is pervasive and debilitating, and a major barrier to
administrators of community agencies and the overall community recovery. Self-stigma occurs when an individual who has a mental
itself. Given this complexity, the means to provide PSR vary, depending illness believes the negative views that others hold. Stigma and work
on the geographic, cultural, economic, political, social and organizational are inter related, getting a job and keeping a job is a challenge.
characteristics of the settings where PSR is provided.’ [WHO/MNH/
MND/96.2] Models of rehabilitation which are in use currently are day care
services, half way homes, long stay homes and community based
Invariably rehabilitation starts after remission of active or severe rehabilitation. Newer methods at NIMHANS are out patient
symptoms; and in an admitted patient, after discharge; by many rehabilitation, in patient rehabilitation and home based rehabilitation.
professionals, discharging to home is considered as rehabilitation.
Long stay homes, mainly run by private or by NGOs, are alternative
Ideally, rehabilitation should start from first contact and assessment,
hospitals or like reinstitutionalisation, which take care of homeless
a beginning should be made and should be carried on simultaneously
mentally ill and those likely to be lonely in future. A small proportion
with medical treatment. The focus should vary with course of illness,
will always need this facility.
remission and recovery.
Day care programme is effective in reducing the burden on the
Rehabilitation is usually provided for chronic disorders, after many
family, gives family respite from patient care, and reduces expressed
months or years of illness, for those not responding or partially
emotion. Day care allows regular follow up and supervision of
responding or those with remitting and relapsing disorders. Though
PSR is provided for those with severe mental disorders, psychoses, medications, development of work habits and vocational training, an
alcoholism and substance use disorders, it can also be provided for opportunity for job placement, employment, self employment, sheltered
other mental health problems like depression, personality disorders workshops and various psychosocial interventions can be offered.
and obsessive compulsive disorders. Currently, such programmes are found in mental health institutes and
centres, and a model for general hospital settings and nursing homes
The common rehabilitation needs are related to work, care of
needs to be developed.
personal hygeine, social interaction and adjustment and family and
marital functions. The need to work, have a job is significant as it Family based rehabilitation includes an active role of family in
provides self-esteem and identity, a sense of self worth and social initiating treatment, continuing care and support. Family caregivers
status. Likewise the need to earn is considered important both by the want their patient engaged in some gainful employment. Leisure time
individual and the family. During rehabilitation, there is a great difficulty activities are not seen as that important but these are helpful in overall
finding and holding on to a job in open employment. Hence, there are well being of the person. Supportive family environment may be related
needs for vocational training and income generating activities. A to better outcome of severe mental disorders in India. Patients and
positive attitude towards persons with mental illness, to be wanted by family members seek income generating rehabilitative activities to
the family and society is yet another important need. limit disability and simultaneously augment family finances. Financial
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assistance for such families can be suggested. Since almost all of our UNDERSTANDING THE CONCEPT
mentally ill persons are still with their families, efforts on psycho
education, rehabilitation counseling and CBR programmes are needed.
OF DISABILITY
*
In PSR centres, common training or vocational sections are Naveen Kumar. C
carpentry, plastic and blow moulding, arts and crafts, bakery, candle The World Health Organization defines disability as an umbrella
making, bamboo basket making, weaving, tailoring and a computer term including all impairments, activity limitations and participation
section. Common services provided are vocational counselling and restrictions. Impairment is a term which refers to dysfunction of an
training, activity scheduling and social skills training to name a few. organ of the body. Activity limitation refers to difficulty in carrying
Psychiatric rehabilitation programmes help the person with mental out a task or a function of that particular organ. Participation restriction
illness and the family by giving them an occupation, financial gains, means, the limitation, a person has in performing his/her role in the
social reintegration, enhancing self esteem and confidence, reduction society ([Link] The term
in stigma, continuing medical attention, improving treatment adherence, ‘disability’ encompasses and replaces previous terms such as
enabling independence in self care, extending support to the family, ‘impairment’ (dysfunction of a particular organ or part of the body)
and lastly providing a meaning and purpose in life (spiritual aspects). and ‘handicap’ (the social disadvantage a person experiences because
Persons with a disability are entitled to disability certificates, disability
of his impairment and consequent role restriction).
pensions and reservations in jobs.
The National Sample Survey Office (NSSO) which has surveyed
Psychiatric rehabilitation should be a part of standard psychiatric
persons with disabilities three times in the past three decades, defines
care. It is an integral part of the routine treatment and will ensure
disability as “any restriction or lack of abilities to perform an activity
that a large number of persons can benefit. There is professional
resistance, especially from psychiatrists, and other mental health in the manner or within the range considered normal for a human
professionals, mainly due to their training or lack of facilities. Maybe being (NSSO, 2003)”.
the term rehabilitation has become stereotyped, outdated, and out of The draft of the Rights of Persons with Disabilities Act of India
fashion and there is a need for a change of terminology to a more (2012) defines ‘person with disability’ as a person with long-term
dynamic and positive term like Recovery Oriented Services, or physical, mental, intellectual or sensory impairment which, in
Recovery Oriented Care / Practice. There is also a need for interaction with various barriers, may hinder his/her full and effective
indigenous, creative, low cost approaches, which are cost effective,
participation in society on an equal basis with others
feasible, realistic, and culturally relevant models. These models need
to have a balance of work, and fun oriented rehabilitation. Few other organizations such as International Labour Organization
Rehabilitation services should be built into existing infrastructure for (ILO) and the United Nations have given similar definitions of the
mental health services and should be linked with other disabilities. term ‘Disability’. The essence of all these definitions is that there is
_______________ some sort of restriction on fulfilling a person’s role in his/her society/
* Professor & Head, Psychiatric Rehabilitation Services I/C Department of Psychiatry, community that is caused by an interaction between various factors
National Institute of Mental Health & Neurosciences, Bangalore (the illness of the person with all its consequences and the barriers
6 PSYCHIATRIC REHABILITATION PSYCHIATRIC REHABILITATION 7

that society creates for such an ill person). In contrast to the medical within countries. Populations with high rates of socioeconomic
view, the social concept of disability posits that the society has created deprivation have the highest need for mental health care, but the
many barriers (both physical and attitudinal) for optimal functioning lowest to access it. Human resources available for mental health
of persons with disability. In keeping with this new concept, there is care in most low and middle income countries are very limited. People
a paradigm shift in understanding and developing services to those with mental illnesses are also vulnerable to abuse of their human
with disability in recent decades. rights. Stigma associated with mental illnesses also interferes with
Mental Illness and Disability the use of available resources. Moreover, the available resources
are used inefficiently (Saxena et al., 2007).
Mental disorders are heterogeneous in nature and include varied
range of behavioural deficits. Consequently, different disorders have Mental retardation is defined as a condition of arrested
differing patterns of disabilities. In addition, there are fundamental development of the mind especially characterized by impairment of
ways in which mental disability differs from its physical counterpart; intellectual functioning. These deficits manifest during the
a) Psychiatric disability is dynamic in nature. For example, a person developmental period. Apart from the compulsory impairment of
with schizophrenia might be quite disabled when he/she is off- adaptive behaviour, these individuals experience other mental disorders
treatment and not so during the period of good treatment adherence. at least three to four times more commonly than in the general
b) Social and work related aspects are more important dimensions of population. In addition, individuals with MR are at higher risk of
psychiatric disability than locomotion and sensory functioning. c) exploitation and physical/sexual abuse (WHO 1992). Needless to
Psychiatric disability may not be visible to the naïve/ignorant external say, these individuals are all disabled and would require a great deal
observer contributing to the stigma and discrimination. For example, of support from the society through-out their life.
there are instances where patients have been denied of disability Existing data on Severe Mental Disorders (SMDs) and
benefits from authorities simply because they don’t ‘look’ disabled. Mental Retardation
Notwithstanding these inconsistencies, psychiatric disorders form A meta-analysis (Reddy & Chandrashekar 1998) of 13
the most disabling medical disorders especially the severe mental epidemiological studies give the following prevalence estimate for
disorders (schizophrenia and bipolar affective disorders) and
SMDs (Schizophrenia, Bipolar disorders, Unipolar depression, Organic
developmental disorders (such as mental retardation, autism etc).In
Psychoses) in India: 15.4 per 1000 population (95% CI=13.5-17.4)
low and middle income countries such as ours, the global burden of
When mental retardation was considered, the estimate was 6.9 per
schizophrenia as measured by the Disability Adjusted Life Years lost
1000 population (95% CI=6.0-7.8). Given the Indian population, these
(DALYs) amounts to 15.2 million years and that of bipolar affective
form a burgeoning public health problem. In addition, a recent survey
disorder amounts to 12.9 million years. Both disorders account for
by the National Sample Survey Organization (NSSO) in 2003 gave
3% each of Years Lived with Disability (YLDs; Collins et al., 2011).
the nationwide (and state-wide estimates as well) estimates for persons
Moreover, resources for mental health are very much lower than with disability. A stratified multi-stage sampling design was adopted
is needed, based on the proportionate burden of mental disorders. for the survey. Rural and urban blocks were surveyed separately.
Additionally, they are also inequitably distributed between regions The ultimate stage units were households-group of persons normally
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living together and taking food from a common kitchen. A total of two conditions put together form 10% of the total ‘disabled’ population
around 70,000 households were surveyed across the country. With of the country. The survey also gave the following estimates for
regard to mental disability, persons who had difficulty in understanding Karnataka state: prevalence of MR was 1/1000 and prevalence of
routine instructions, who could not carry out their activities like others mental illness (SMDs presumably) was 0.5/1000.
of similar age or if he/she had exhibited behaviours like talking to Around 10% of the world’s population is disabled (80% of these
self, laughing/crying, staring, violence, fear and suspicion without live in developing countries). Though the existing human rights
reason were considered as disabled. Activities like others of ‘similar conventions offer considerable potential to promote and protect the
age’ included activities of communication (speech), self-care (bathing, rights of persons with disabilities, this potential was not being tapped.
clothing, eating, personal hygiene etc), home living (doing some Persons with disabilities continued being denied their human rights
household chores) and social skills. The mentally disabled were divided and were kept on the margins of society in all parts of the world. In
into two groups viz: mentally-retarded and mentally ill. In the survey, response to these, recently, the United Nations adopted a convention
the following three probing questions were asked to classify them as to set out the legal obligations on States to promote and protect the
mentally retarded and mentally ill; rights of persons with disabilities ([Link]
• Is there anyone in the family who has difficulty in understanding accessed on 28 February 2013). It does not create new rights however.
instruction, who does not carry out his/her activities like others India being one of the signatories to this convention is bound to change
of his/her age or exhibits behaviours like talking to self, laughing/ its laws in accordance with this development. It is noteworthy that in
crying without reason, staring violence? our country, developments are already underway in this direction and
the existent Persons with Disabilities Act 1995 is on its way for
• If the response was affirmative to the question above, it was modification.
asked whether the behaviour was observed since birth/
Another related development is that there has been a paradigm
childhood but before 18 years of age?
shift in understanding the concept ‘disability’. According to this,
• Was he/she late in talking, sitting, standing or walking? disability is an ‘evolving’ concept. It results from the ‘interaction’
If the response to these three questions were all in affirmative, between persons with impairments on the one hand and attitudinal
then the person was categorized as mentally retarded. On the other and environmental barriers on the other that hinders their full and
hand, if the response to the first question was in affirmative but effective participation in the society. Persons with disabilities include
responses for the other two questions were not both in affirmative, those who have long-term physical, mental, intellectual or sensory
then the person was categorized as mentally ill. (NSSO, 2003).When impairments which in interaction with various barriers may hinder
it comes to the estimated numbers, our country has about 10,00,000 their full and effective participation in society ([Link]
persons with mental retardation and 11,00,000 persons with severe disabilities/; accessed on 28 February 2013).
mental disorders (presumably). These figures translated to the As the concept of disability has evolved, so are the means of
following prevalence rates: 94/1,00,000 persons for mental retardation measuring it. This has led to the development of International
and 105/1,00,000 persons for mental illness (SMDs presumably). These Classification of Functioning (ICF) by the World Health Organization
10 PSYCHIATRIC REHABILITATION PSYCHIATRIC REHABILITATION 11

(WHO). The ICF puts the notions of ‘health’ and ‘disability’ in a new In addition, the WHO and the World Bank in their summary of
single dimension. It posits that all human beings do experience a the World Report on Disability (2011), recommend the following among
decrease in health and hence experience some degree of disability at others:
some point during their life. In addition, ICF takes into account the
• Invest in specific programs and services for people with
social aspects of disability and does not see disability only as a medical
disabilities
or biological dysfunction. By measuring the environmental factors,
ICF allows to record the impact of the environment on the persons’ • Adopt a national disability strategy and plan of action
functioning. Essentially, ICF includes the classification of health and • Improve disability data collection
health-related dimensions. It includes the following parts:
measurement of impairments (both body functions and structure);
• Support and strengthen research on disability
measurement of limitations in activities and participation restriction ([Link]
and finally the environmental (contextual: includes physical, social
Work on Psychiatric Disability in India
and attitudinal environment) factors. The environmental factors include
both barriers and facilitators ([Link] In India, majority of the work has been done on schizophrenia.
en/; accessed on 9 March 2013). Many dimensions of disability have been explored including tools to
measure disability, determinants of disability, course of disability,
WHO purports that using ICF as a universal framework for
comparison of disabilities related to various psychiatric disorders etc.
disability data collection will help create better database and yield
themselves to comparisons across different sources of data. In a With regard to the assessment tools, Schedule for Assessment of
call for improving national disability statistics, WHO gives the steps Psychiatric Disability (SAPD) measures disability across social,
that can be taken to improve disability data collection. Some of these personal, occupational and global domains. Social Functioning Index
are: employing ‘difficulties in functioning approach’ instead of an (SSFI) is another instrument with an advantage of its validity being
‘impairment approach’: this better captures the extent of disability; established by community level workers as well. It includes four
data collection in line with international organizations such as United sections – self-concern, occupational role, family role and other social
Nations Statistical Commission; dedicated disability surveys to gain roles. Indian Disability Assessment and Evaluation Scale (IDEAS) is
in depth information on disability and functioning; collecting longitudinal one of the most popular scales to measure psychiatric disability in
data on disability: the study of cohorts and their environments over India. The rehabilitation committee of the Indian Psychiatric Society
time allow researchers and policy makers to understand better the (IPS) developed IDEAS (IPS Rehabilitation Committee, 2002)
dynamics of disability. Such analyses would give better indications of recognized by the Government of India, for certifying psychiatric
what happens to patients and their families after disability onset, how disability. Another issue is that IDEAS is being used by many research
their situation is impacted by public policy changes; the causal studies across the country. Another instrument being used is the Social
relationship between poverty and disability, and how and when to Occupational Functioning Scale (SOFS), which is meant for use
start prevention programs, modify interventions and make among caregivers of patients with schizophrenia. Adaptive living skills,
environmental changes ([Link] social appropriateness and interpersonal skills are the main domains
2011/[Link]). of functioning that could be assessed by SOFS (Saraswat et al., 2006).
12 PSYCHIATRIC REHABILITATION PSYCHIATRIC REHABILITATION 13

Disability due to schizophrenia has a milder course in India when However, going by the experience, the proportion of patients/
compared with that in developed countries. Also, basic interventions families that are getting benefits out of these schemes is likely to
such as providing antipsychotics alone can reduce the disability at remain low because of the various barriers that are mentioned above.
the community level. For example, Thirthalli et al. (2009) reported Future directions
significant reduction of disability with antipsychotic treatment alone
1. India being one of the signatories of the United Nations
in a south Indian cohort after one year of follow-up – disability
Conventions on the Rights of Persons with Disabilities 2008,
continued to be substantial and unchanged in patients who refused has taken step forward to revamp the PWD 1995. The rights
antipsychotic medications. Treatment adherence can go a long way oriented disabilities act 2012, is out in the draft form for further
in reducing the disability of patients with schizophrenia in the same refinement.
cohort (Suresh et al., 2012). These interventions can be provided at a
2. To relook at the existing lacunae with regard to mental
fairly low cost (Srinivasa Murthy et al., 2005) as well. These findings disabilities and legislation (BadaMath, 2011) and see to that
suggest that at the bare minimum, antipsychotic treatment should be these lacunae are addressed in the new legislation
made available to all those who are in need. It is noteworthy however
3. The need to consider psychiatric disability as separate from its
that in the above communities, there remained a sizeable proportion
physical counterpart and the consequent need to bring in special
of patients who did not improve with medications alone. Needless to
sub provisions with respect to certifications and disability
say they would require more comprehensive long-term care. In this benefits
connection, a model of community based rehabilitation (CBR;
Chatterjee et al., 2003) has been shown to be better than routine 4. Increasing awareness of the nature of mental disabilities so
that there is an inclusive development of the communities
outpatient treatment across several domains of disability at first year
follow-up. 5. Increasing awareness on the already existing provisions and
to simplify means of obtaining them.
Existent provisions for those with mental disability:
6. To reduce the barriers that persons with disabilities face
Some of the important provisions are as follows
7. To refine measures of disability so that they could capture all
1. Enactment and the consequent provisions of the Persons with important dimensions of mental disability
Disabilities Act (1995).
8. Research to increase comprehensive understanding on all
2. Dysfunction arising out of mental illnesses are being accorded aspects of mental disability
the status of disability 9. To develop and advocate locally relevant treatment models
3. Provisions for various disability benefits that could reduce disability

4. Job reservations for those with mental disability 10. Establishment of the National Institute for Mental Health
Rehabilitation with the vision of co-ordinating all activities
5. Benefits under the various Rojgar Yojanas related to mental disabilities
_______________
6. Income tax benefits
*Assistant professor, Department of Psychiatry
7. Family pensions National Institute of Mental Health & Neurosciences, Bangalore.
14 PSYCHIATRIC REHABILITATION PSYCHIATRIC REHABILITATION 15

References: and Behavioral Disorders in India: A Meta-analysis. Indian

J Psychiatry 1998; 40: 149-157.
• Chatterjee S, Patel V, Chatterjee A, Weiss HA. Evaluation
of a community-based rehabilitation model for chronic • Saraswat N, Rao K, Subbakrishna DK, Gangadhar BN.
schizophrenia in rural India. Br J Psychiatry 2003;182:57- The Social Occupational Functioning Scale (SOFS): a brief
62. measure of functional status in persons with schizophrenia.
Schizophr Res. 2006;81:301-309.
• Collins PY, Patel V, Joestl SS, March D, Insel TR, Daar
AS; Scientific Advisory Board and the Executive • Saxena S, Thornicroft G, Knapp M, Whiteford H.
Committee of the Grand Challenges on Global Mental Resources for mental health: scarcity, inequity, and
Health, Anderson W, Dhansay MA, Phillips A, Shurin S, inefficiency. Lancet 2007; 370: 878-879.
Walport M, Ewart W, Savill SJ, Bordin IA, Costello EJ, • Srinivasa Murthy R, Kishore Kumar KV, Chisholm D,
Durkin M, Fairburn C, Glass RI, Hall W, Huang Y, Hyman Thomas T, Sekar K, Chandrashekar CR. Community
SE, Jamison K, Kaaya S, Kapur S, Kleinman A, Ogunniyi outreach for untreated schizophrenia in rural India: a
A, Otero-Ojeda A, Poo MM, Ravindranath V, Sahakian follow-up study of symptoms, disability, family burden and
BJ, Saxena S, Singer PA, Stein DJ. Grand challenges in costs. Psychol Med 2005; 35: 341-51.
global mental health. Nature. 2011 Jul 6;475(7354):27-
30. doi: 10.1038/475027a. • Suresh KK, Kumar CN, Thirthalli J, Bijjal S, Venkatesh
BK, Arunachala U, Kishorekumar KV, Subbakrishna DK,
• Math SB, Nirmala MC. Stigma haunts persons with Gangadhar BN. Work functioning of schizophrenia
mental illness who seek relief as per Disability Act 1995. patients in a rural south Indian community: status at 4-
Indian J Med Res 2011;134:128-30. year follow-up. Soc Psychiatry Psychiatr Epidemiol. 2012;
• Ministry of Social Justice and Empowerment, Government 47: 1865-71.
of India, The Draft Rights of Persons with Disabilities • Thirthalli J, Venkatesh BK, Kishorekumar KV,
bill, 2012. [Link] Arunachala U, Venkatasubramanian G, Subbakrishna DK,
accessed on 6 March 2013. Gangadhar BN. Prospective comparison of course of
• National Sample Survey Office (NSSO), 2003. Disabled disability in antipsychotic-treated and untreated
Persons in India. Report No. 485 (58/26/1). http:// schizophrenia patients. Acta Psychiatr Scand. 2009; 119:
[Link]/mospi_new/upload/485_final.pdf (Accessed 209-217.
on 19 february 2013). • United Nations. [Link] accessed
• Rehabilitation Committee of the Indian Psychiatric Society on 28 February 2013.
(IPS). Indian Disability Evaluation and Assessment Scale • World Health Organization; [Link]
(IDEAS); Indian Psychiatric Society, New Delhi, 2002. disabilities/en/; accessed on 28 February 2013).
• Reddy MV, Chandrashekar CR. Prevalence of Mental • World Health Organization. Summary of the world report
16 PSYCHIATRIC REHABILITATION PSYCHIATRIC REHABILITATION 17

on disability; [Link] INTERNATIONAL PERSPECTIVE ON

WHO_NMH_VIP_11.01_eng.pdf;accessed on 2 March
REHABILITATION
2013.
*
Praveen Venkatachalam,
• World Health Organization 1992. Mental and behavioural **
Avinash Waghmare,
disorders. Clinical descriptions and diagnostic guidelines. ***
Geetha Desai
Geneva.
There has been a change in approach to various diseases in terms
• World Health Organization: [Link]
of transformation in emphasis from ‘consequences of disease’ to
classifications/icf/en/, accessed on 9 March 2013.
‘components of health’. This has been evident from revision of
• World Health Organization. [Link] International Classification of Impairment, Disability and Handicap
disabilities/world_report/2011/[Link]; accessed on (ICIDH- 1980) by World Health Organization (WHO) to International
28 February 2013 Classification of Functioning, Disability and Health (ICF- 2001). ICF
describes human functioning and its restrictions in two parts i.e.
components of functioning and disability and components of contextual
factors. The first part describes body functions both physiological
and psychological activities and participation of a person in various
activities. The second part describes the importance of environmental
and personal factors. This is more applicable to psychiatric illnesses.
It helps in understanding the functioning and disability of persons
with the psychiatric illness at body, personal and societal level. This
in turn helps in planning rehabilitation of the person.
According to WHO, Rehabilitation is “a set of measures that
assist individuals, who experience or are likely to experience disability,
to achieve and maintain optimum functioning in interaction with their
environments”. These measures are focused on bodily functioning,
personal factors and environmental factors.
Psychiatric rehabilitation comprises of a comprehensive mental
health system which assist individuals with mental illnesses in
developing various skills (social, emotional, cognitive, intellectual and
physical skills) that are required to live as normally and independently
as possible in a community. This system also focuses on modifying
the stressful environment to enhance optimum functioning of the
individual.
18 PSYCHIATRIC REHABILITATION PSYCHIATRIC REHABILITATION 19

In 2005, a global survey of the implementation of the non-binding, and professionals in various areas like health, education, vocational
United Nations Standard Rules on the Equalization of Opportunities and social services. It promotes awareness, self-reliance and
for Persons with Disabilities was conducted. responsibility for rehabilitation within the community.
As many as 114 countries had responded in the survey. It was Components of CBR:
found that: 1. Prevention of cause of disability
- In 50% countries legislation on rehabilitation for people with 2. Provision of care facilities.
disabilities was not passed;
3. Creating a positive attitude towards people with disabilities.
- In 42% countries rehabilitation policies were not adopted;
4. Provision of functional rehabilitation services.
- In 40% countries rehabilitation programmes were not established.
5. Empowerment, provision of education and training
There have been lots of developments in the area of psychiatric opportunities.
rehabilitation considering the long term disability with mental illness.
Various regions in the world have various views and policies that are 6. Creation of micro & macro income-generation
being implemented according to the available resources and socio- opportunities.
cultural practices. The focus now is shifting from center-based 7. Management / monitoring and evaluation of CBR projects
rehabilitation to more helpful community based rehabilitation.
Supported Services:
In all these different interventions, the common framework for
1. Supported Education: It is a psychiatric rehabilitation
assessment involves establishing symptomatic status of the patient,
approach which prepares persons with psychiatric disabilities
finding real life circumstances in day-to-day life of the patient and
to achieve educational goals. The person is supported at
identifying personally relevant goals for the patient. It is followed by
various levels from preparing a person to choose a course,
working with the patient hand-in-hand and establishing supportive
getting a course and engaging him in the course till he/ she
network for the patient. While formulating rehabilitation plan, culture
finishes it. This is done by training in stress management,
is considered as the most important factor.
improving academic skills, teaching problem solving, building
We will discuss strategies/ programmes practiced globally in the self-confidence, making use of disability benefits etc.
beginning followed by specific programmes in some regions
2. Supported Employment: Through this service person with
General strategies/ programmes practiced globally: psychiatric disability is placed in competitive employment. As
per the person’s choice and abilities he/she is placed in a job
Community based rehabilitation (CBR): CBR has been
and continuous supported is provided thereafter.
promoted by WHO as a strategy within general community for
rehabilitation, equalization of opportunities and social inclusion of all 3. Supported Housing: As part of the assertive community
children and adults with disabilities. It is implemented through combined treatment (described in the next page), persons with severe
efforts of persons with disabilities, their families and communities mental illness are given supported housing facilities.
20 PSYCHIATRIC REHABILITATION PSYCHIATRIC REHABILITATION 21

Some perspectives of various regions in psychiatric rehabilitation Western Pacific Region:

are different and hence will be discussed specifically with each In this region, Biwako Millennium Framework (BMF) for Action
geographic region. was adopted as a roadmap for psychiatric rehabilitation for the Asian
Europe: and Pacific Decade of Disabled Persons (2003-2012). It focuses
mainly on implementing CBR.
Community Mental Health Teams (CMHT): Psychiatric
rehabilitation is a concerted effort of the members of the rehabilitation Australia:
team, patient and family members. CMHTs have been present in The rehabilitation services have evolved from the services
UK for more than 40 years. CMHT used to be comprised of discussed above (mainly assertive community treatment). These
psychiatrist, social workers and nurses. Over the years it has been services are;
found that though these three groups are essential for care, but only
1. Targeted assertive and intensive case management
their work was not sufficient. Hence other members like psychologists,
vocational trainers and experts in various areas of rehabilitation were 2. Comprehensive rehabilitation assessment approach
also included in the team. The functions of the team are to supervise 3. Various support services for housing, education, work
treatment given to patients in primary care and treat patients with etc.
severe illness, who cannot be handled by primary care. 4. Development of various skills
North America: _______________
* Non-PG Junior Resident,
A basic model for community support for persons with severe * * Senior Resident
Department of Psychiatric Rehabilitation Services
mental illnesses developed in Maddison (US) is called as Assertive ***Associate Professor,
Community Treatment (ACT). It is delivered by multidisciplinary team Department of Psychiatry, National Institute of Mental Health & Neurosciences,
Bangalore
comprising of psychiatrists, nurses, psychologists, social workers,
psychiatric aides, vocational trainers, etc. It delivers comprehensive
management including medication management, providing help in
finding house, money management, managing household, developing
social support, providing supported education and employment, training
in various skills required for living, etc. The team takes care of specific
number of patients around the clock, seven days a week.
The goals of ACT are to minimize symptoms, prevent recurrences
of illness, enhance quality of life and improve the functioning of
affected individual. ACT and various adaptations of it are being
implemented across many states in the US for more than 30 years.
22 PSYCHIATRIC REHABILITATION PSYCHIATRIC REHABILITATION 23

References: CARE AND SERVICES IN PSYCHIATRIC

• National Alliance on Mental Illness (NAMI). Assertive REHABILITATION
Community Treatment (AST) Availableat:http:// *
Nirmala.B.P,
[Link]/[Link]? Section = About_ **
Usha Kiran.K.T,
Treatments_ and_Supports&template=/ ***
Faseela Jaleel
C o n t e n t M a n a g e m e n t /
[Link]&ContentID=8075 Accessed 29 Apr Rehabilitation is a process aimed at enabling the affected individual
2013. to reach and maintain the optimal level of functioning at the physical,
psychological, social, intellectual, perceptual and sensory levels. The
• World Health Organisation (2001) International psychiatric rehabilitation in essence comprises of intervention
Classification of Functioning, Disability and Health (ICF). strategies at two levels. The first level focuses on the individual-
Geneva, Switzerland: WHO. centered intervention that aims at developing the patient’s skills in
• Royal College of Psychiatrists London (2004) Community interacting with stressful environment. The second level, ecological
mental health care. London: Royal College of centered, aims at developing the environmental resources to reduce
Psychiatrists. the potential stressors. In a majority of incidences both levels of
interventions are equally important. These interventions help the
• Rossler, W. (2006); Psychiatric rehabilitation today: an disabled to attain the required independence and self-confidence.
overview. World Psychiatry, 5(3), 151-157.
India is credited to be the first developing country to formulate
• Soydan, A. S. (2004); Supported Education: A Portrait of the National Mental Health Programme (NMHP) based on the
a Psychiatric Rehabilitation Intervention. American principles of decentralization and de-professionalization of the mental
Journal of Psychiatric Rehabilitation, 7, 227–248. health care. India’s booming population has created a place for itself
as the second most populous country in the world. However, the
• Bond, G. R. (2004); Supported employment: evidence for
growing population is also catering to the growing needs for the care
an evidence-based practice. Psychiatric Rehabilitation
of the mentally ill in both institutional and non-institutional settings
Journal, 27, 345-359
(though not adequately).
The earlier strategies of caring for the mentally ill emphasized
more on pharmacology and psychotherapy without much attention to
facilitating daily functioning and social interaction. Gradually the focus
of care was shifted to de-institutionalization where greater numbers
of mentally ill were aimed at being treated in their own home/
community settings than the mental institutions.
Ananthkumar (2011) reports that many NGOs and the civil society
groups have actively engaged in creating a number of half way homes,
24 PSYCHIATRIC REHABILITATION PSYCHIATRIC REHABILITATION 25

day care centers, long stay homes, counseling centers, suicide support the involvement of persons in the normal community
prevention and community based programmes for the mentally ill as activities such as school, occupation, social events and like all
part of their extension clinics that are located in urban centers though through the process of rehabilitation
the rural areas are not given due attention.
13) The essential ingredient in the process of rehabilitation and
Some important aspects of rehabilitation recovery is the involvement and partnership of the family
1) Recovery is the ultimate goal of rehabilitation and hence, members and the persons receiving the services
interventions must facilitate the process of recovery 14) Practitioners should constantly strive to improve the services
2) Help people to re-establish normal roles in the community and they provide (International Association of Psychosocial
their reintegration into community life Rehabilitation Services)

3) Facilitate the development of personal support networks Building a new rehabilitation unit, a new hospital, rehab clinic in
general hospital may be too expensive as large amount of resources
4) Facilitate an enhanced quality of life and build strength in every
(structural and functional) are needed. But when the same services
individual receiving the services
could be rendered at the client’s doorsteps, it becomes more affordable
5) Each and every individual has the capacity to learn and grow and effective.
6) Every individual receiving the services has the right to direct Non-institutional services are recommended by several national
his/her own affairs including those that are related to one’s and international agencies and the government too, as they involve
mental illness the community people in the rehabilitation process. “Nothing should
7) Every individual has to be treated with respect and dignity be imposed on them, without them” seems to be the driving motto
behind community participation. Community level interventions view
8) Practitioners must make conscious and consistent efforts to mental illness as a community problem and involves mobilization of
eliminate labeling and discriminating, especially discrimination resources, with the help of family, community people and
based on the disabling conditions decentralization of service delivery. At the community level, the lay
9) Culture and ethnicity plays a significant role in the recovery as volunteers, community workers, staff in advocacy organizations,
sources of strength and enrichment for the individual and the coordinators of self-help/user groups, humanitarian aid workers,
services traditional health workers and other professionals such as teachers
10) Services are to be coordinated and made accessible and and police officers can play a major role in serving the needs of the
available as long as needed mentally ill. Many of these informal community-care providers have
little or no formal mental health care training, but in many developing
11) All services are to be designed to address the unique needs of countries they are the main source for making the mental health care
the individuals, consistent with the individual’s cultural values services reach the grass root level. They are the major facilitators in
and norms the integration of people with mental disorders into the community,
12) Psychosocial rehabilitation services actively encourage and and thus play a recognizable supportive role to formal mental health
26 PSYCHIATRIC REHABILITATION PSYCHIATRIC REHABILITATION 27

services. (WHO, 2005). In India, the role of non-specialist personnel employment by hand holding in providing raw materials, market
in various mental health initiatives have been well accepted for over for finished goods.
25 years (Srinivasa Murthy, 2004).
There are several indicators showing that the camps were
Camps instrumental in involving the village leaders in the therapeutic process
In India, rural extension centres or outreach camps are popular and helped to reduce stigma against mentally ill.
for eye care, dental and immunization services and now mental health Services in primary health care:
has also joined the bandwagon.
Primary Health Care Centers cater to the largest number of people
Features and Roles of Camp in Psychiatric Rehabilitation with mental disorders. In normal circumstances, about 20% of those
Services: seeking primary care are known to suffer from different mental
1. Camps are organized by liaising with the leaders of the disorders. It plays a vital role in preventing the patients being wrongly
community, teachers, youth, Block Development Officers, diagnosed and given non-specific and inappropriate treatment and
doctors, etc. The date and duration are fixed following an in- also subjecting them to unwanted investigations. By providing
depth discussion. People friendly locations are identified for effective care at this level, the stigma of mental disorders is reduced.
the same. It is to be noted that this approach is cost-effective. Apart from
2. A multi-disciplinary team of doctors visit the camp, screen the providing the above mentioned, the staff at the PHC level are also
patient and provide medical and non-medical treatment at a able to devote more time the patients and their family members by
very nominal cost or sometimes at free of cost. actively listening to them, by providing guidance and useful information
about techniques to improve their daily routine activities, mobilizing
3. Camps utilize the local youths for help in dispensing medicines,
the family resources and formation of groups of patients for self-
maintaining case files, bringing the mentally ill to the camp and
also the follow-up of the treated patients. help(WHO, 2008).

4. Since the camps are hosted by the local organizations, Services in institutional settings
accommodation and hospitality will also be provided by them Institutional care proves very beneficial to those individuals who
only. lack adequate family or community support. More often these
5. Owing to the informed networks with politicians, police, health institutions have a greater proportion of individuals with mental health
workers, mahila mandals, the sustainability of the camp is needs. Some of the common mental disorders that require institutional
ensured because of the collective efforts. care are acute and chronic psychoses, mental retardation, dementia
and drug dependence. In spite of the advantages, the institutional
6. The camp can provide sensitization programme for the mentally
settings may sometimes fail to provide adequate care, social contacts,
ill, vocational counseling and collaboratively promote self-
daily routines and opportunities for the fulfilment of one’s needs and
employment by identifying livelihood options and thereby
promote recovery. capacities due to limited staff and over- crowding of the patients.
This can further add on to the emotional distress experienced by the
7. The camps can ensure that family is involved in patients’ self mentally ill. This warrants sensitising the staff of institutions to
28 PSYCHIATRIC REHABILITATION PSYCHIATRIC REHABILITATION 29

emotional needs of the residents; training the medical staff in mental Psychiatric Day Care Centres form an important part of
health care; providing coping skills to the residents; creating psychiatric community services and care. Here the persons who are
opportunities for emotional fulfilment through education, hobbies, free from active symptoms are provided with required therapeutic
entertainment, forming relationships and engaging in productive intervention during daytime. The primary objective of day care training
activities. centers is rehabilitation of patients with disabilities, rather than the
Services in Medical College/Psychiatric Institutions treatment of psychiatric illnesses. Hence, there are no doctors and
nurses. The key professionals involved are social workers and
The total mental health programme is vastly supported by the
occupational therapists. Patients are usually expected to stay in the
mental health institutes, the psychiatry departments of at medical
centre for rehabilitative training for about nine months. While receiving
colleges and general hospitals. In these institutions/departments/
training in the centre, patients have to return to psychiatric out-patient
hospitals, a number of specialized mental health professionals work
for the welfare of the psychiatrically ill with the specialized facilities clinics for follow-up from time to time. It is an ideal environment for
available with them. The functions carried out by them include medical giving occupational therapy, vocational training, social skills training,
consultation to the district psychiatrists, health center’s medical officer family interventions and family welfare services. A wide range of
with regard to “difficult” cases of psychiatric disorders, admit and structured activities are provided at each of the Day Centres and the
provide brief hospital treatment for psychiatric patients, specialized programmes are individualized as far as possible to meet the needs
treatments, incorporating rehabilitation. of each patient.
They also provide training for specialist mental health human These centres basically aim at providing the psychiatrically ill
resources, namely psychiatrists, clinical psychologists, psychiatric patients with vocational orientation and rehabilitation. It also provides
social workers and psychiatric nurses, the undergraduate medical the recovering patients an opportunity for social interaction skills,
students, medical officers, health personnel, general practitioners. In learning of skills to improve self-esteem and self help-care. The cost
addition, they also issue monthly disability certification and monthly of establishing and maintaining this kind of centers are very low.
data of psychiatric care. Those seeking this service are also provided with professional care
Short and Long Term Care: in the form of individual and group therapy. These centres decrease
the burden on the family of continuous care by providing them with
These are the decentralized centers of rehabilitation in the
community. Providing care and services close to the places of respite care.
residence of patients decreases the delay in seeking help as well as Halfway Homes:
help in easier and fuller reintegration of the recovered patients into
These homes provide rehabilitation services for a limited period.
the community. It also decreases the stigma of long stay in institutions.
The inmates are taken in on the basis of the homogeneity of the
Voluntary organizations have a very important role to play in these
diagnosis. It is also known by the names ‘recovery house’ or ‘sober
activities. Some of the types of facilities that should be part of the
house’. In situations where the patients need supervised care but not
total mental health care system are outlined below.
amounting to that of the hospital, with an emphasis on psychosocial
Day Care Centres: rehabilitation and the benefits of therapeutic community, these centres
30 PSYCHIATRIC REHABILITATION PSYCHIATRIC REHABILITATION 31

are valuable. Half way homes generally allow its residents to gradually towards independence. There are dangers of these centres becoming
begin the process of reintegration into the society while still providing ‘mini mental hospitals’ along with possible human rights abuses.
monitoring and support. It is generally believed that these homes reduce
Hostels and sheltered accommodations/vocational training
the risk of recidivism or relapse when compared to integrating the centres /sheltered workshops:
patients directly into the community. During this period of stay,
emphasis is on both therapy and rehabilitation. Depending on the Shelters are defined as ‘buildings offering emergency overnight
accommodation to single homeless people’. Hostels are defined as
orientation of the centre and the staff, various therapeutic modalities
buildings offering boarding and lodgings to single homeless people.
would be used for recovery purposes. An important part of the therapy
Because of their different functions, shelter and hostel accommodation
is the work with the family so that the family is ready for receiving
tend to cater for different populations. Shelter accommodation caters
the recovered patient along with the patient learning the skills to live
for a transient population consisting of whoever happens to turn up
at home and community.
on a particular night, where as hostel accommodation caters for a
Quarter Way Home: relatively ‘permanent’ group of ‘residents’, who will live in the hostel
by day and occupy the same bed, or room, at night. For recovered
Quarter way home is an intermediate step between living in a
and rehabilitated patients, income generation is an important factor.
hospital ward and living in the community. Located inside the hospital
These facilities will provide both an opportunity to earn a living as
compound but not having the same strict hospital environment, intended
well as the protection of a therapeutic setting in which trained staff
to ease the transition of patients from in-patient wards to the
will give the support. The possibilities for the clients to develop
community. Less restrictive, less supervision, nursing staff as
cooperatives should be encouraged.
supervisors, less of ward rounds. Patients given responsibility of tasks
in the ward such as cleaning, serving food, etc, placed in hospital Domiciliary Care/Home Care:
duties such as laundry, dietary section, records section, etc. Here Home care aims to make it possible for people to remain at home
patients may not need acute medical cure but cannot be discharged rather than use residential, long-term or institutional-based nursing
because of the clinical conditions. The patients are kept only for a care. Home care providers render services at the clients’ home. These
short time. services may include some combination of professional health care
services. The counselor will go in the guise of a friend to assess the
Long Stay Homes:
need, build a rapport with the client. He fosters inter-personal
Long stay homes are a group phenomenon and becoming a relationship among family members, strengthens family dynamics,
necessity. These places are meant for the abandoned mentally ill develops a structured routine, emphasizes the need for medication
owing to the reasons relating to some of the severe and chronic mental and provides it at home under the guidance of a doctor who is seeing
disorders, the changing family situations (preference of nuclear families the patient. This kind of care is highly beneficial for those who are
over joint families) and the stigma of seeking local psychiatric help. helpless or unwilling to go to hospital. They may be individuals living
The challenge of care in these centres are to provide humane living alone or living with elderly parents.
conditions, respect the rights of the ill persons, and to orient their stay Other Systems of Mental Health Care
32 PSYCHIATRIC REHABILITATION PSYCHIATRIC REHABILITATION 33

India is home to large number non-allopathic systems of care. References:

This ranges from the well established health systems of Ayurveda, • Director General of Health Services: National Mental
Homeopathy, Unani systems who all have their own approaches to Health Programme for India. New Delhi, Ministry of
mental health care (Somasundaram,2009, Srinivasa Murthy.R, 2010). Health and Family Welfare, 1982.
There are other methods used for mental health care which are well
organized and varies depending on the practitioners like the use of • Murali,T., Rao,K. Psychiatric rehabilitation in India: issues
religious treatments, temples for mental health care (Sebastia,2009). and challenges, In: Agarwaal, S.P., Goel, D.S., Ichhpujani,
R.L., Salhan, R.N., Shrivatsava, S.(2004) Mental Health-
_______________
* Associate Professor, An Indian perspective(1946-2003), Directorate General
* * Junior Research Fellow (DST funded Project on ASD) of Health Services, Ministry of Health and Family Welfare,
Department of Child and Adolescent Psychiatry
National Institute of Mental Health & Neurosciences, Bangalore New Delhi. 152-160.
***PhD Scholar
Department of Psychiatric Social Work • Sebastia,B. Restoring mental health in India-pluralistic
therapies and concepts, Oxford, New Delhi.2009.
• Somasundaram,[Link], literate and cultural
approaches to mental disorders in Tamil Nadu, In: Sebastia,
B. Restoring mental health in India-pluralistic therapies
and concepts, Oxford, New Delhi.2009. 27-47.
• WHO. Mental health in Primary care- International
developments, WHO-WONCA, Geneva. 2008.
• WHO. Promoting mental health, concepts, emerging
evidence, practice, WHO, Geneva. 2005.
34 PSYCHIATRIC REHABILITATION PSYCHIATRIC REHABILITATION 35

PSYCHO-EDUCATION AND understandable to them. There is evidence that psycho-education

EDUCATIONAL MATERIAL ON improves adherence to treatment and other outcomes of mental
illnesses. The person imparting psycho-education should have the
SELECTED PYSCHIATRIC ILLNESSES basic skills of interviewing patients with mental illnesses and their
*
Avinash Waghmare, families.
**
Jagadisha Thirthalli As stated above, psycho-education has four important goals:
Introduction: 1. Imparting knowledge about the condition: The section on
Psycho-education may be conceptualized as a process of sharing 'patient and family education material' will provide most of the
knowledge about mental illness in a therapeutic context (a) to help relevant information in this regard.
patients and family caregivers understand their illness, (b) to provide
2. Providing support to the individual diagnosed with mental illness
support, as the diagnosis of mental illness may have evoked significant
and / or his family members: The diagnosis of MI / ID has
negative emotions, (c) to enable them to face the challenges of living
serious implications and may evoke significant negative
with mental illness and (d) to involve them as active participants in
emotions in individuals and their family members. The
their own recovery process.
professional imparting psycho-education should be sensitive
This chapter is written in such a way that professionals with to this and should have skills to manage such situations. Some
minimal formal training in mental health field should be able to provide points in the following box may be helpful in this regard:
basic education about schizophrenia and related disorders (i.e., Box-1: Tips for ensuring optimal emotional
psychosis), bipolar disorder and intellectual disability. While psychosis atmosphere during psycho-education
and bipolar disorders are considered to be mental illnesses (MI),
• Establish rapport and therapeutic relationship with
intellectual disability (ID, also known as mental retardation) is not
the patient / family members
regarded as an illness. However, in some places in this chapter we
have referred to all three conditions as mental illnesses for the sake • Have an empathic attitude and unconditional positive
of convenience. Information regarding each of these conditions has regard
been provided in a language that is understandable by non-professional • Use techniques of active listening
(lay) individuals. • Validate their feelings of distress / anxiety / anger /
General considerations about psycho-education: despair
It is imperative that every individual diagnosed with a mental • Show utmost respect for patients' / family members'
illness as well as his/her family should have access to the relevant differential opinion regarding any issues related to
details about the illness and its treatment. It is the right of the patients their illness and its treatment
and their families to know about their illness. It is also the bounden 3. To enable them to face the challenges of living with mental
duty of the professionals to provide it in the manner that is illness: The section on 'patient and family education material'
36 PSYCHIATRIC REHABILITATION PSYCHIATRIC REHABILITATION 37

and other chapters in this book as well as other resources Ideally, both patient and primary caregivers should be the recipients
provide different sources of help for the different needs of the of psycho-education. However, appropriate sensitivities must be
individuals with MI / ID and their families. observed. For instance, in case the patient does not want certain of
his family members to know regarding certain aspects of his/her illness,
4. To involve them as active participants in their own recovery
his/her wish may have to be respected. Alternatively, a floridly
process: Patients and families may expect the treating team to
symptomatic patient with poor insight may not be included in the
make several important decisions and plans for them in the
initial psycho-education sessions conducted with his/her family
context of their MI / ID. This is especially true in the Indian
members.
context, where doctor-patient relationship may be influenced
by the 'Guru-Chela' concept. While preserving the advantages Certain tips for the professional providing psycho-education:
of this concept, the professional should encourage patients/ • Make sure that the treating team is reasonably confident about
families to actively plan for their recovery process. The patient the diagnosis: providing the diagnosis of a mental condition
/ family should be encouraged to be active participants of the may have serious implications on the patient's and the family
implementation of treatment plans as well. members' lives. Hence, psycho-education should be provided
The process of psycho-education: only if there is reasonable confidence regarding the same.

Psycho-education should start informally at the very first contact • Do explore what the patient/family already knows about the
with the mental health professional. However, it is not uncommon to illness: The advantage of exploring this first up is that you will
observe that some patients/families do not even have basic knowledge be able to discover many myths that they may be having about
about their illness despite being in treatment for several years. the illness. Certain myths about mental illness and mental
retardation are given in the box below.
Depending on the situation, initial session should cover at least about
10-15 minutes of in-person education. Reading materials or electronic • If you are not confident of answers to any question, do frankly
media references may be provided at this stage with an expectation express your ignorance and seek clarifications from authentic
that patients / relatives would find answers to most of their questions sources. One need not feel that the patient/family would think
through this. One or two more sessions of in-person education would low of him/her if he/she admits not knowing some fact. Indeed,
be helpful in clarifying their doubts. it is more likely that the patient/family would appreciate the
professional for his/her honesty and commitment to provide
As a number of facts are similar across different patients, a group
them with correct information.
approach may be time-efficient. A group approach also has several
other advantages, including sense of self-help group, social learning, • Do not give false hopes for the sake of temporarily reassuring
learning from others' experience, etc. However, differences in socio- the patient/family. Such reassurances will remain temporary.
economic status, education, language, personality factors and other The professional may lose his/her credibility in the eyes of
practical difficulties may make group sessions difficult. Moreover, patients/families.
some sensitive issues may need to be addressed only in individual • After you have completed the session, check if they have any
sessions. more questions in mind.
38 PSYCHIATRIC REHABILITATION PSYCHIATRIC REHABILITATION 39

Box-2: Common myths about mental illness and its Box-3: Common myths about intellectual disability:
treatment:
• There are medicines/other treatments to improve
• It is caused by evil spirits / black magic / curse of intelligence
God or Evil
• The patient's intelligence keeps improving as he/she
• It is caused by lack of avenue for sexual experience:
ages and he/she will become normal
marriage will hence cure the illness
• It is caused by faulty parenting, too much or too less • The person with ID is lazy and hence acts as if he
disciplining does not know things
• It is caused by studying too much • Certain religious rituals will cure his/her problems
• The patient is deliberately behaving abnormally
• He/she will be cured if he/she gets married
• Mental illness has no treatment
• Mental illness is always hereditary Patient / Family Education Material

• Psychiatric medications are simply sedatives Schizophrenia:

• Psychiatric medications are addictive: the person The doctors have diagnosed you / your family member to be
becomes dependent on them suffering from schizophrenia. This write up will provide you with
some details about schizophrenia. (If your doctor has given a different
• Psychiatric medications cause harm to vital organs diagnosis but yet we have told you to read this, please go ahead and
of the body when taken for long periods of time read further, as most of the issues will be applicable to your case too,
• Psychiatric medications are very 'powerful' and they as these are similar conditions).
make the person 'weak'
Not all patients who have schizophrenia experience the same
• Medications can be stopped once the person type of illness. This variation is similar to other medical problems like
improves diabetes- the disease may be the same, but each individual patient
• One should control one's symptoms by willpower may have a different experience: some may have very mild diabetes,
and not through medications which is controllable with diet and exercises; some others have to
take different types of tablets and some have to take insulin injections
daily. Similarly, different patients with schizophrenia may have
variations in terms of symptoms they have, the way they behave,
their view about their own illness, their response to treatment, etc.
This material is going to give you an overall idea about you/your
relative's condition. Please feel free to ask us questions/doubts after
you read this.
40 PSYCHIATRIC REHABILITATION PSYCHIATRIC REHABILITATION 41

Symptoms of schizophrenia: decide, plan, etc. These symptoms can improve to some extent
Frequently asked questions by extra efforts as mentioned above and may require special
training.
• Does he/she have any illness?
4. Other symptoms: These are emotional problems like feeling
• What are the symptoms of the illness? tense, pounding heartbeat, worries about future, anxiety about
• Why does he/ she behave like this? doing things and interacting with others, feeling low, not enjoying
things that he/she used to enjoy earlier, feeling worthless, under
Schizophrenia is a medical illness. Just like how various medical confident, etc. Some patients may express desire to die and
illnesses affect the body, schizophrenia affects a person's brain and may attempt suicide. Irregular sleep and eating habits are also
mind. Individuals with schizophrenia have varied symptoms. common. Many patients with schizophrenia may also be
Commonly they talk / smile to themselves without obvious reason; addicted to tobacco, alcohol, etc. Medicines as well as
they may not mingle with others as they used to do previously; they counselling may be required for treating these symptoms. Your
get angry easily sometimes without obvious reason; not taking proper patient may have symptoms which may not be listed above.
personal care (not taking bath, not brushing / changing clothes), talking Feel free to ask your doctor about it.
about strange things, being suspicious, fearful without apparent reason, Many patients with schizophrenia do not believe that they have
etc. Most often the patient will not realize that he/she is ill and will any mental illness and may not appreciate the seriousness of their
resist any attempt to help him/her. It may be useful to understand condition and the need for treatment. Because of this, he/she may
symptoms under the following heads: refuse to take treatment.
1. Positive symptoms: These include suspiciousness (others are Causes of schizophrenia:
trying to harm or talking about him/ her etc.), talking strange
Frequently asked questions:
things, hearing of voices which others are unable to hear, etc.
These symptoms usually improve with medications. • Why did this illness occur?
• Is it hereditary?
2. Negative symptoms: These include not engaging in meaningful • Is it caused by black magic?
activities, not speaking much, not taking care of one's own • Is it caused by tension? By studying too much?
routine / career etc. These symptoms improve only minimally
with medicines. These symptoms will require efforts from About 4-5 in 1000 people, between the ages 16 and 50 develop
patient, family and the treating team, such as motivating the schizophrenia. The number of people who suffer from schizophrenia-
patient to do daily activities, keeping him/her occupied in like conditions is about the same as those who suffer from epilepsy
activities, etc. (fits), stroke (paralysis) or vitiligo. The cause for schizophrenia is not
clearly known. In most patients it occurs because of multiple reasons,
3. Cognitive symptoms: These include not being able to
which may or may not be obvious to you.
concentrate, forgetting things, not getting thoughts, inability to
42 PSYCHIATRIC REHABILITATION PSYCHIATRIC REHABILITATION 43

1. Subtle changes in the brain: You may observe that not all individuals who face stress develop
schizophrenia; we also know that some patients with schizophrenia
Schizophrenia may be caused by certain changes in patients'
would not have faced any significant stress. It appears that whether
brains. These changes are subtle and involve some chemicals that
a person develops schizophrenia due to stress depends on his/her set
nerve cells produce. These are called neurotransmitters (e.g.
of genes: if he/she has certain set of genes, he/she may develop
dopamine, serotonin, etc.). It is also believed that nerve cells are
schizophrenia no matter how little stress he/she faces. On the other
connected to one another in a different/improper manner in brains of
hand, some may even face a lot of stress without developing
individuals with schizophrenia. Because of these reasons, functions
schizophrenia, as their genes may protect them against the adverse
of different brain parts may become excessive or deficient. These
effects of stress. An example of a volcano may help you to understand
changes result in changes in patients' behaviour. The changes in the
this. The boiling lava represents stress and the plate of earth between
brain are generally subtle, scanning or other tests may not be of any
the lava and the surface represents the genes. Some persons are
help in most cases to identify these changes.
born with a thin plate (risky genes) - even a small amount of lava
2. Genes: (stress) will result in volcanic eruption (schizophrenia). Some are
Changes in the brain described above are largely due to the born with very thick plates (protective genes) - there will be volcanic
problems in the genes of the patients. You may know that we are eruption (schizophrenia) only when the amount of lava (stress) is of
born with a set of genes that we inherit from our parents. Each one grave nature.
of us is unique and different from others because we carry different 5. Use of certain substances
combinations of genes. It is believed that some combination of genes
Use of substances (e.g., amphetamines, cannabis, etc.) may also
may make a person vulnerable to develop schizophrenia (see below
cause schizophrenia, again, in those who are genetically at risk of
under "stress"). As a result, we observe that relatives of person with
developing it.
schizophrenia have more risk of developing schizophrenia. However,
since many genes are involved and other factors are also important Misconception about the cause of Schizophrenia:
in causing schizophrenia, most individuals who have relatives with • Black magic
schizophrenia do not develop the illness. Similarly, many patients with
schizophrenia may not have anyone else in the family with similar • Faulty food
illness. • Faulty parenting
3. Subtle injuries to brain: • Evil eye ( Drishti / Nazar)
Any minor injury to the brain before birth (e.g., malnutrition, Treatment:
infection or use of harmful medications during pregnancy), during Frequently asked questions
birth or after birth may increase the risk of developing schizophrenia.
• Is there any treatment which can cure this illness?
4. Stress: • What are the types of treatment available?
Different forms of stress including adverse social circumstances, • How long the treatment should be given?
personal problems (exams, relationship difficulties), family problems, • If he/she develops other medical problem what should
financial and occupational difficulties etc., may lead to schizophrenia. be done about his psychiatric medicines?
44 PSYCHIATRIC REHABILITATION PSYCHIATRIC REHABILITATION 45

There are two main forms of treatment for schizophrenia. Both Commonly, patients and families stop taking medicines for a number
are equally important: of reasons including improvement in symptoms, side effects, lack of
insight and lack of knowledge about how long to take medications,
1. Medicines
etc. It is important to consult your doctor before stopping treatment.
2. Psychological, social and related interventions. The doctors may decide to stop your medications depending on a
1. Medicines: number of factors, including your risk for relapse, impact that a possible
relapse may have on your education/job/personal life, etc. You may
Medicines are an essential part of the treatment of schizophrenia. discuss with your doctor regarding the option of stopping medications
Commonly used medications are: Risperidone, Olanzapine, Quetiapine, periodically, but it is important to note that a majority of patients with
Haloperidol, Fluphenazine, Clozapine, etc. As you would have read schizophrenia have risk of relapse if medications are discontinued.
above, subtle chemical changes occur in the brains of persons with
In most cases, medications given for psychiatric illnesses may be
schizophrenia. Medications are given to minimize these changes.
continued even when the patient experiences other medical problems.
Medications will generally show their effect after a few days or
However, you should show your doctor the medications that you are
weeks. Doctors generally start low doses of medications and
taking and check whether you should continue it and if so, whether at
depending on the benefit and side effects, adjust their dose.
the same dose or not.
Doctors will make maximal efforts to avoid side effects, but Many patients, who have experienced improvement with
despite this, you may expect a few side effects to occur. Increase in medications, report that they feel better after stopping medicines.
sleep, tremors of hands, stiff feeling in the body, increased salivation This happens because when they stop medications, they stop
and tiredness are common ones. Many patients experience weight experiencing side effects of the medicines like stiffness, sleepiness,
gain and changes in the sugar and cholesterol levels in blood. The tiredness, etc., and symptoms of schizophrenia do not reappear
doctors may advise blood tests to detect these early. The side effects immediately after stopping medications. However, after a few days
can be minimized after discussion with your doctor. Medicines like or weeks or months, the symptoms may restart and on some occasions,
Trihexyphenidyl and Procyclidine may be given to treat some side it may be difficult to treat a relapse. HENCE, CONSULT YOUR
effects. It is important to remember that side effects are generally DOCTOR BEFORE STOPPING MEDICINES FOR WHATEVER
more during the initial weeks of treatment and will gradually reduce REASON.
when the dose of medications are reduced. Generally smoking, drinking alcohol and use of other drugs should
Duration of treatment: be avoided by psychiatric patients, as they can affect illness and also
reduce effect of medications. Even if patient takes these drugs,
Generally treatment is continued for several months and
psychiatric medications should not be stopped.
sometimes years. This is because many patients experience relapse
if medicines are stopped (see "What to expect in future?"). The
treatment should be continued with regular follow ups with your doctor.
46 PSYCHIATRIC REHABILITATION PSYCHIATRIC REHABILITATION 47

Myths about medication back to their education / work, etc., are crucial in their recovery. The
• Psychiatric medicines are only sedatives. table below shows some behaviours of the patients with schizophrenia
and how the family should react to them.
• These medicines are addictive.
Psychological, social treatment measures other than
• These medicines damage kidneys/liver /eyes etc. medications are as important as medications for the patients
• These medicines are very powerful and will make with schizophrenia. The patients and families should take active
the patient weak. part in their recovery and should be prepared to provide extra
time and efforts required for these interventions.
2. Psychological, social and other treatments:
Challenging behaviours of patients with schizophrenia:
Medications are essential for treating schizophrenia. However,
mere medication would not suffice. Medications will yield optimal
results only if a number of other measures like regular exercise, diet
and stress-free lifestyle are also adopted. Many patients face problems
like lack of motivation, difficulty in concentration, forgetfulness, etc.
Moreover, the patients may have difficulties in interacting with people,
controlling their emotions and may have family and social problems.
These have been mentioned above as negative, cognitive and other
symptoms. These symptoms may not improve with medicines alone.
Patients with these challenges may benefit from regular counselling,
training in improving concentration, memory, engaging in hobbies and
productive occupation, etc. Individual and / or family counselling is
available for dealing with these challenges. Psychologists, psychiatric
social workers, psychiatric nurses and psychiatrists themselves can
help patients and families in these difficulties.
The role of patients themselves, their family members, friends
and relatives and of the society is as important as that of doctors/
therapists in these measures. It has been observed that in developing
countries like India, patients with schizophrenia have better outcome
than patients in developed countries. One of the possible reasons can
be the support and protection given by the families and the society to
the patients. The love and care provided by the families, their role in
supervising medications, their support in helping the patients in getting
48 PSYCHIATRIC REHABILITATION PSYCHIATRIC REHABILITATION 49

able to remain symptom free if treatment is stopped (Figure-1). A

majority of patients experience repeated relapses of the illness, most
of them because they stop medications and a few even while taking
medications. Though patients who experience relapse also improve
after re-starting or adjusting the dosage of the medications, some of
them may have incomplete improvement in between episodes
(Figures-2 and 3). Each relapse may cause disruption in the patient's
education / work / relationships; with each relapse the patient's
confidence may go down and the family members may get frustrated.
Hence, it is best to avoid relapses. The best method of avoiding relapse
is to take medications as prescribed by the psychiatrists. Though
schizophrenia is described by many as a severe mental disorder, it is
only a small number of patients that do not recover from their first
episode of illness despite treatment (Figure-4). Patients who do well
with treatment have the features listed in the box (Prognosis box)
Figure 1:

Please note: Patients do not deliberately act differently, but they

do so because of the disease.
Keep these to the minimum: Direct criticism of the patient
and having arguments with him/her.
A warm and friendly attitude helps in all situations.
What to expect in future?
Frequently asked questions Figure 2:
• Will this illness occur again?
• Is it a lifelong illness?
• Will he/she ever get alright?
Most individuals who develop schizophrenia improve substantially
with treatment. Following improvement, the doctors start reducing
the dose of medications very gradually. Only a few patients will be
50 PSYCHIATRIC REHABILITATION PSYCHIATRIC REHABILITATION 51

Figure 3: Marriage and issues related to children:

Figure 4:

Marriage:
Many believe that marriage cures patient from psychiatric illness.
It is not true. However, marriage of patients with schizophrenia is a
complex issue and the decision regarding it should be taken after due
consideration of the following issues;
1. The disorder as well as the medications given for its treatment
may alter the sexual desire and performance in both men and
women. Fortunately, in most cases, doctors will be able to
address these issues. The ability to beget children is not seriously
affected in these patients. However, women who are receiving
medications should discuss regarding their plans for conception
with their psychiatrists – as some medications will have to be
avoided during early months of pregnancy, they may suggest
alternative treatments. Moreover, as the doses of medications
have to be adjusted through the pregnancy and delivery, they
will have to be in constant consultation with their psychiatrists.
2. The patients and their families should carefully think whether
the patient is in a proper condition to have a meaningful
relationship with his/her spouse and the new family. As
marriage could be stressful, especially in situations where the
patient has to move to another family, there may be chances
of relapse. The family should have reasonable confidence that
52 PSYCHIATRIC REHABILITATION PSYCHIATRIC REHABILITATION 53

the patient will be able to handle the stress. The other issue is professionals. Some of them have conquered their schizophrenia to
the ability of the patient to lead independent life (financially). even win the Nobel Prize!
3. A common question is whether the children of the patient will Bipolar Disorders
develop schizophrenia. As schizophrenia is caused partly by The doctors have diagnosed you / your family member to be
genetical factors, the risk for children of persons with suffering from bipolar disorder (BD). This write up will provide you
schizophrenia is higher compared to children of those who do with some details about BD. Not all patients with BD experience the
not have schizophrenia. The risk is estimated to be about 10% same type of illness. This variation is similar to other medical problems
(about 10 times more). Seen from another perspective, there like diabetes– the disease may be the same, but each individual patient
is about 90% chance that children of patients with schizophrenia may have a different experience: some may have very mild diabetes,
may NOT develop schizophrenia. Unfortunately, it is difficult which is controllable with diet and exercises; some others have to
to predict whose child may develop schizophrenia. take different types of tablets and some have to take insulin injections
All these issues are important considerations for the would-be daily. Similarly, different patients with BD may have differences in
spouse and his/her family too. It is imperative that both parties discuss terms of type of symptoms they have, the way they behave, their
about these issues before the marriage. However, commonly this response to treatment, how frequently they fall ill, etc. This material
does not happen and the families get patients with schizophrenia is going to give you an overall idea about BD. Please feel free to ask
married without disclosing the illness. The consequences of such us questions/ doubts after you read this.
actions on the patient’s illness and relationship are highly unpredictable. Symptoms of BD:
Commonly, family members expect the doctors to decide whether Frequently asked questions
the patient could get married. It is important to note that while it is
• Does he/she have any illness?
important to discuss such issues with the doctors, the final decision
should be taken by the patient and the family members. The doctors • What are the symptoms of the illness?
will be willing to discuss different aspects of marriage, but will refrain • Why does he/ she behave like this?
from making decisions for the families.
Bipolar disorder is a medical illness. Just like how other medical
We have attempted to provide an overview of the condition that
illnesses affect the body, it affects a person’s brain and mind. Patients
you / your relative have/has. You may have additional questions. We
with BD generally have episodes of illness and periods of normalcy.
urge you to discuss with your doctors/therapists regarding any
About 1 in 100 people may suffer from this and it commonly starts in
questions that you want to ask about your health. late teens or early twenties. There are typically two distinctive phases:
Final words: Don’t be hopeless about your / your relative’s life high and low.
just because you/he/she have/has this illness. A large number of The high phase is called as mania (or hypomania if it is not too
patients with schizophrenia have been able to lead nearly normal severe). During this phase, the patient feels excessively happy (or
lives with their own efforts, support from their families and healthcare angry) and full of energy throughout the period of illness, which may
54 PSYCHIATRIC REHABILITATION PSYCHIATRIC REHABILITATION 55

last for weeks to months on end. During this period, he/she talks
excessively and rapidly (sometimes he/she speaks without stopping
for others to respond), spends money unnecessarily (may buy things
that may not be needed or may buy things unmindful of how much
they may cost), remains very active and tries to do many things at a
time (he/she may not be able to sit at a place for more than a few
minutes). He/she may remain so active that he/she hardly sleeps be
it night or day. He/she may lose sense of inhibition and may sing or
dance or talk about issues that he/she would hesitate to talk when
normal (e.g., sexually explicit language, abusive language etc.). He/
she would become over confident and think high of him/her (he/she Most patients with bipolar disorder have periods ranging from a
may claim to be famous or to know famous people or to have a lot of few weeks to several years when they remain free of mania and
money/property); he/she may make big plans for his/her or others’ depression. While some patients have very frequent episodes of mania
sake. He/she may decorate him/herself repeatedly and in a flashy
or depression, others may experience them once in several years. A
manner.
few patients have minor changes in their mood even during the so-
The low phase is called depression. A patient with depression called normal period. It should be noted that professionals call mania
feels low / sad throughout the period of illness, which may last for / depression only (a) when the symptoms are serious enough to cause
weeks to months on end. There may or may not be any reason for significant distress or disruption in daily activities and (b) only if they
feeling sad. He/she may be found to be tearful or crying easily. He/ last for several days or weeks continuously (minor changes in mood
she may not enjoy things he/she would have enjoyed previously (e.g., and behaviour as described above occur normally in everyone’s life
watching TV / listening to music / reading, etc.). He/she tends to get and these are not illnesses).
tired easily and wants to rest frequently; he/she may become very
Many patients with BD do not believe that they have any mental
slow in his/her activities. His/her thinking also becomes slow and he/
illness and may not appreciate the seriousness of their condition and
she may find it hard to concentrate on even routine activities. He/she
the need for treatment. Because of this, he/she may refuse to take
would not mingle with others as earlier. He/she would lose confidence
treatment.
and would feel that he/she is worthless and even burdensome to the
family. Sometimes he/she may feel excessively guilty and may think Causes of BD:
of having committed sins. He/she may feel that there is no help or Frequently asked questions:
hope for better future and may like to end their lives. He/she may • Why did this illness occur?
express ideas of death / suicide or attempt to commit suicide. He/she • Is it hereditary?
may sleep / eat too much or too less and may lose / put on weight • Is it caused by black magic?
unusually. Sometimes he/she may fear that people will harm him/her • Is it caused by tension? By studying too much?
or they may be talking ill about him/her.
56 PSYCHIATRIC REHABILITATION PSYCHIATRIC REHABILITATION 57

The cause for BD is not clearly known. In most patients it occurs face stress develop BD; we also know that some patients with BD
because of multiple reasons, which may or may not be obvious to would not have faced any significant stress. It appears that whether
you. a person develops mania / depression due to stress depends on his/
her set of genes: if he/she has certain set of genes, he may develop
1. Subtle changes in the brain: BD may be caused by certain
mania/depression no matter how little stress he/she faces. On the
changes in patients’ brains. These changes are subtle and involve
other hand, some may face even a lot of stress without developing
some chemicals that nerve cells produce. These are called
BD, as their genes may protect them against the adverse effects of
neurotransmitters (E.g., dopamine, serotonin, etc.). It is also believed
stress. An example of a volcano may help you to understand this.
that nerve cells are connected to one another in a different/ improper
The boiling lava deep inside the earth represents stress and the plate
manner in brains of individuals with BD. Because of these reasons,
of earth between the lava and the surface represents the genes.
functions of different brain parts may become excessive or deficient.
Some persons are born with a thin plate (risky genes) - even a small
These changes result in changes in patients’ behaviour. The changes
amount of lava (stress) will result in volcanic eruption (mania /
in the brain are generally subtle - scanning or other tests may not be
depression). Some are born with very thick plates (protective genes)
of any help in most cases to identify these changes.
– there will be volcanic eruption (mania/depression) only when the
2. Genes: Changes in the brain described above are largely amount of lava (stress) is of grave nature.
due to problems in the genes of the patients. You may know that we
4. Use of certain substances (e.g., amphetamines, cannabis,
are all born with a set of genes that we get from our parents. Each
etc.) may also cause BD, again, in those who are genetically at risk
one of us is unique and different from others because we carry
of developing it.
different combinations of genes. It is believed that some combination
of genes may make a person vulnerable to develop BD (see below 5. Disruption in sleep: It is commonly observed that disruption
under “stress”). As a result, we observe that relatives of BD have in sleep pattern due to any reason (e.g., studying for exams / travelling
more risk of developing BD. However, since many genes are involved / shift work, etc.) triggers mania / depression in those who are
and other factors are also important in causing BD, most individuals vulnerable to develop BD.
who have relatives with BD do not develop the illness. Similarly,
These things don’t cause Bipolar Disorder
many patients with BD may not have anyone else in the family with
similar illness. • Black magic

3. Stress: Different forms of stress including adverse social • Faulty food

circumstances, personal problems (exams, relationship difficulties), • Faulty parenting
family problems, financial and occupational difficulties etc., may lead
• Evil eye (Drishti / Nazar)
to mania or depression. You may observe that not all individuals who
58 PSYCHIATRIC REHABILITATION PSYCHIATRIC REHABILITATION 59

Treatment: gain and changes in the sugar and cholesterol levels in blood. The
Frequently asked questions doctors may advise blood tests to detect these early. The doctors
may also ask you to get blood tests to measure the level of the
• Is there any treatment which can cure this medication in your body. This will help them in adjusting the dose of
illness? the medication to avoid side effects. The side effects can be minimized
• What are the types of treatment available? after discussion with your doctor. Medicines like trihexyphenidyl,
procyclidine, propranalol etc. may be given to treat some side effects.
• How long the treatment should be given?
It is important to remember that side effects are generally more during
• If he/she develops other medical problem what the initial weeks of treatment and will gradually reduce when the
should be done about his psychiatric medicines? dose of the medications are reduced.
There are two main forms of treatment for BD. Both are equally Duration of treatment:
important:
Generally treatment is continued for several months and
1. Medicines and sometimes years. This is because many patients experience relapse
2. Psychological, social and related interventions. if medicines are stopped (see “What to expect in future?”). The
treatment should be continued with regular follow ups with your doctor.
1. Medicines:
Commonly, patients and families stop medicines for a number of
Medicines are an essential part of treatment of BD. Commonly reasons including improvement in symptoms, side effects, patients’
used medicines are called mood stabilizers (e.g., lithium, valproate, refusal to take medicines, lack of knowledge about how long to take
oxcarbazepine, lamotrigine, etc.). When the patient’s mania is severe, medications, etc. It is important to consult your doctor before stopping
doctors may prescribe additional medications like risperidone, treatment. The doctors may decide to stop your medications depending
olanzapine, quetiapine, haloperidol, chlorpromazine, etc. When the on a number of factors, including your risk for relapse, impact that a
depression is severe, additional medications like fluoxetine, possible relapse may have on your education/job/personal life, etc.
escitalopram, sertraline, bupropion, etc., may be used. As you would You may discuss with your doctor regarding the option of stopping
have read above, subtle chemical changes occur in the brains of medications periodically, but it is important to note that a majority of
persons with BD. Medications are given to minimize these changes. patients with BD have risk of relapse if medications are stopped.
Medications will generally show their effect after a few days or In most cases, medications given for psychiatric illnesses may be
weeks. Doctors generally start low doses of medications and continued even when the patient experiences other medical problems.
depending on the benefit and side effects, adjust their dose. However, you should show your doctor the medications that you are
Doctors will make maximal efforts to avoid side effects, but taking and check whether you should continue it and if so, whether at
despite this, you may expect a few side effects to occur. Increase in the same dose or not.
sleep, tremors of hands, stiff feeling in the body, increased salivation Many patients, who have experienced improvement with
and tiredness are common ones. Some patients experience weight medications, report that they feel better after stopping medicines.
60 PSYCHIATRIC REHABILITATION PSYCHIATRIC REHABILITATION 61

This happens because when they stop medications, they stop challenges may benefit from regular counselling, training in improving
experiencing side effects of the medicines like stiffness, concentration, memory, engaging in hobbies and productive
sleepiness, tiredness, etc., and symptoms of mania/depression do occupation, etc. Individual and / or family counselling is available for
not reappear immediately after stopping medications. However, dealing with these challenges. Psychologists, psychiatric social
after a few weeks or months, the symptoms may restart and on workers, psychiatric nurses and psychiatrists themselves can help
some occasions, it may be difficult to treat a relapse. HENCE, patients and families in these difficulties.
CONSULT YOUR DOCTOR BEFORE STOPPING MEDICINES
The role of patients themselves, their family members, friends
FOR WHATEVER REASON.
and relatives and of the society is as important as that of doctors/
Generally smoking, drinking alcohol and use of other drugs therapists in these measures. The love and care provided by the
should be avoided by psychiatric patients, as they can affect families, their role in supervising medications, their support in helping
illness and also reduce effect of medications. Even if patient the patients in getting back to their education / work, etc. are crucial
takes these drugs, psychiatric medications should not be stopped in keeping the patients well.
Myths about medication Measures other than medications are as important as
medications for patients with BD: Patients and families should
• Psychiatric medicines are only sedatives.
take active part in their recovery and should be prepared to
• These medicines are addictive. provide extra time and efforts required for these interventions.
• These medicines damage kidneys/liver /eyes etc. What to expect in future?
• These medicines are very powerful and will Frequently asked questions
make the patient weak.
• Will this illness occur again?
2. Psychological, social and other treatments: • Is it a lifelong illness?
Medications are essential for treating BD. However, they are • Will he/she ever get alright?
not sufficient. Medications will yield optimal results only if a number
of other measures are also adopted. This is similar to the case of Nearly all patients who develop mania / depression improve
other medical conditions like diabetes, hypertension, etc., where, other substantially with treatment. Following improvement, the doctors start
measures like regular exercise, diet and stress-free lifestyle are as reducing the dose of medications very gradually. Most patients
important as medications. Many patients face problems like difficulty experience repeated episodes of mania and / or depression if they
in concentration, memory, planning, unstable mood, problems with are not on regular treatment. If they take treatment as prescribed,
decision making, irregular sleeping / eating / working habits. Some the risk of relapse can be minimized, though the risk cannot be
patients may have difficulties in their intimate relationship, problems completely eliminated. Patients who experience relapse improve after
in controlling their emotions and may have family and social problems. re-starting or adjusting the dosage of the medications. Each relapse
These may not improve with medicines alone. Patients with these may cause disruption in the patient’s education / work / relationships;
62 PSYCHIATRIC REHABILITATION PSYCHIATRIC REHABILITATION 63

with each relapse the patient’s confidence may go down and the trying to argue or reason out with the patients when they feel / behave
family members may get frustrated. Hence, it is best to avoid relapses. unusually. To the extent possible you may be supportive to them, try
The best method of avoiding relapse is to take medications as to pacify them when they become disturbed and take due care of
prescribed by the psychiatrists and to ensure that you do not lose patients’, others’ and your safety.
sleep for whatever reason
If the patient is expressing suicidal ideas do take them seriously.
Prognosis Box: Patients who are likely to have good This may be because patient may be depressed. Reassure the patient
outcome and try to instil hope. Keep a close watch on patient. As patients with
BD can take extreme steps quickly – report this to your psychiatrist
1. Starting of illness after 20-25 years of age
and seek advice.
2. Early treatment
Patients with BD may act in haste and quit their job or break
3. Less frequent and less number of episodes their relationship without much forethought. Hence, if they express
4. Good family and social support such ideas, try and postpone decisions, which may have serious
consequences.
5. Those who had good social relationships before
becoming ill Remember that patients do not wilfully act differently, but
they do so because of the disease. Keep these to the minimum:
6. Good response to treatment
direct criticism of the patient and having arguments with him/
7. Following regular treatment as advised by her. A warm and friendly attitude helps in all situations.
doctors
Marriage and issues related to children:
8. Having a job/work
Frequently asked questions
9. Not using addictive substances like alcohol
• Will the illness get cured after marriage?

Frequently asked question: • Can he/ she marry?

Provide us tips about how we should look after the patient when • Can he/she have children?
he/she becomes ill
• Will his/ her children have the same illness?
It is important to note that the patient is feeling and behaving
differently because he/she is suffering from an illness. Just like how
Marriage:
you cannot expect a person with diabetes to control his/her sugar
levels just by ‘making up his/her mind’ or by his/her ‘willpower’, Many believe that marriage cures patient from psychiatric illness.
patients with BD cannot control their feelings and behaviour. It requires It is not true. However, marriage of patients with BD is a complex
the family members to exercise a lot of patience for the medications issue and the decision regarding it should be taken after taking due
to act and the symptoms to come down. Until then, it is best to avoid consideration of few issues;
64 PSYCHIATRIC REHABILITATION PSYCHIATRIC REHABILITATION 65

The disorder as well as the medications given for its treatment whether the patient could get married. It is important to note
may alter the sexual desire and performance in both men and women. that while it is important to discuss such issues with the doctors,
Fortunately, in most cases, doctors will be able to address these issues. the final decision should be taken by the patient and the family
The ability to beget children is not affected in these patients. However, members. The doctors will be willing to discuss different aspects
women who are receiving medications should discuss regarding their of marriage, but will refrain from making decisions for the
plans for conception with their psychiatrists – as some medications families
will have to be avoided during early months of pregnancy, they may
We have attempted to provide an overview of the condition that
suggest alternative treatments. Moreover, as the doses of medications
you / your relative have/has. You may have additional questions. We
have to be adjusted through the pregnancy and delivery, they will
urge you to discuss with your doctors/therapists regarding any
have to be in constant consultation with their psychiatrists.
questions that you want to ask about your health.
The patients and their families should carefully think whether the
Final words: Don’t be hopeless about your / your relative’s life
patient is in a proper condition to have a meaningful relationship with
just because you/he/she have/has this illness. A large number of
his/her spouse and the new family. As marriage could be stressful,
especially in situations where the patient has to move to another family, patients with BD have been able to lead nearly normal lives with
there may be chances of relapse. The family should have reasonable their own efforts, support from their families and healthcare
confidence that the patient will be able to handle the stress. The professionals. Many of them have conquered their BD and achieved
other issue is the ability of the patient to lead independent life a lot in their lives.
(financially). Intellectual Disability
A common question is whether children of the patient will develop The doctors have diagnosed your family member to be having
BD. As BD is caused partly by genetic risk, the risk for children of intellectual disability (ID). This write up will provide you with some
persons with BD is higher compared to children of those who do not details about intellectual disability (ID). Not all patients who have ID
have BD. The risk is estimated to be about 10% (about 10 times experience the same type of problems. This material is going to give
more). Seen from another perspective, there is about 90% chance you an overall idea about ID. You may feel free to ask me questions.
that children of patients with BD do NOT develop BD. Unfortunately,
Frequently asked questions
it is difficult to predict whose child may develop BD.
• Will he/ she become normal?
All these issues are important considerations for the would-be
spouse and his/her family too. It is imperative that both parties discuss • Are there any medicines or surgeries to cure this?
about these issues before the marriage. However, commonly this ID is also known as mental retardation. It is a condition, in which
does not happen and the families get patients with BD married without a person has significant low intelligence affecting his / her functioning
disclosing the illness. The consequences of such actions on the patient’s in many areas of life like personal care, interacting with others, work,
illness and relationship are highly unpredictable.
safety, travel etc. It starts before 18 years of age. The person can
Commonly, family members expect the doctors to decide have slow development (late walking, speaking, etc.) from the
66 PSYCHIATRIC REHABILITATION PSYCHIATRIC REHABILITATION 67

beginning or can have some illness (brain fever, head injury etc.) maximum level of functioning starting with ability to take personal
affecting brain which causes disturbance in development. care, communicate with others, help in household activities, learning
Depending upon the person’s intelligence and functioning, it is things like traveling, handling small amounts of money, taking care of
categorized as mild, moderate, severe and profound. The intelligence personal safety, and engaging in some job and earn for self, depending
is measured by intelligence quotient (IQ). upon the ability. The goals should be realistic and achievable.

• ID is not a psychiatric disorder, it is disorder of development. The training should be planned from the beginning and should be
The people with ID have a greater chance of developing reviewed frequently. Around age of 10-12 years it is better to assess
psychiatric disorder and medical illnesses. the person’s potential to work, so that skills for doing any work can
be taught from this age, as they usually will take time to learn. Training
• The disorder cannot be cured (there are no medicines or
for these skills at a later age (after 20 years of age) is difficult.
surgeries available to treat ID) or reversed, but the persons
with ID can be trained to do many things which normal people Don’t burden them with studies. Encourage schooling till the
can do. person can cope with studies. Schooling is more for developing
interaction with other children, learning skills in day to day activities
• The medicines used for these patients are to treat other
etc.
psychiatric or medical problems.
Some of the things in which persons with ID can be trained
• The people with ID should not be compared with other people,
as this can demotivate them. 1. Taking personal care independently (brushing, bathing,
• Initially it may be easy to do things for the patients (giving dressing, toilet care etc.)
bath, feeding dressing etc.) rather than training them, as it takes 2. Simple household work (sweeping floor, washing clothes,
lot of time and efforts. But, parents should understand that cleaning vessels etc.)
they cannot continue to do these things for the person for his/
3. Bringing things from shop when list of items is given
her entire lifespan.
4. Travelling to fixed places
Training persons with ID:
5. Handling small amounts of money
We will be discussing mainly about training persons with mild
intellectual disability. They can be trained in doing many things with 6. Income generating activities in which patient can be
use of praise and reward, but it should be kept in mind that the learning trained
will be slow compared to other children (If the normal child learns
a. Assistants in number of activities (garage, bakery,
something after teaching him 5 times the child with ID may require
hotels, gardening, printing press, Xerox shop)
teaching 50-100 times and sometimes may not learn it at all).
b. Data Entry
The training should start at the earliest, so that it will be easy to
train them when they are young. The aim should be to achieve c. Electronic assembly
68 PSYCHIATRIC REHABILITATION PSYCHIATRIC REHABILITATION 69

d. Cover making Myths:

e. Mat weaving etc. • With age the person with ID will become normal.
In short, patient can be trained in anything, which is simple • It is a psychiatric illness.
and repetitive
• After marriage it will be cured.
It is unlikely that persons with ID can be trained in following
activities; Marriage:
1. To lead completely independent life Frequently parents wonder whether the person with ID will
2. Take care of household responsibilities become better if he/she is married or can he/ she get married?

3. Cooking for variable number of people or cooking Certainly marriage will not cure the problem. The question that
complex recipes ‘can he/she get married?’ is a complex one. Individuals with ID may
have reduced or increased sexual desire or performance, but they
4. Travel independently to multiple places
can bear children. Whether the offspring of persons with ID will
5. Handling larger amounts of money have ID depends on the cause of ID. Please consult your doctor for
the same.
6. Formal education beyond equivalents of 7-10th Std.
An important consideration before you get him or her married is
Behavioral problems in persons with ID:
whether he/ she is able to understand the challenges of marriage
Persons with ID may show challenging behaviors like getting (having a meaningful relationship with the spouse and family, handle
angry easily, being irregular in activities, talking/ behaving the stress of change in responsibility and place of living etc.) and
inappropriately, being stubborn. Such behaviors are not generally parenting.
treated with medications. Generally they are handled by training family
In our opinion, most will require assistance and support to handle
members in addressing these behaviors without medications.
these challenges.
This training may require several days/ weeks of efforts and
All these issues are important considerations for the would-be
patience from your side and will require you to spend more time with
spouse and his/her family too. It is imperative that both parties discuss
the person with ID.
about these issues before the marriage. However, commonly this
Sometimes these problems may be signs of mental illness, which does not happen and the families get persons with ID married without
may require medications. You need to consult your doctor regarding disclosing the illness. The consequences of such actions on the person’s
this. relationship are highly unpredictable.
Commonly, family members expect the doctors to decide
whether the patient could get married. It is important to note
70 PSYCHIATRIC REHABILITATION PSYCHIATRIC REHABILITATION 71

that while it is important to discuss such issues with the doctors, ISSUES RELATED TO TREATMENT AND
the final decision should be taken by the patient and the family MANAGEMENT IN PSYCHIATRIC
members. The doctors will be willing to discuss different aspects
of marriage, but will refrain from making decisions for the
REHABILITATION SERVICES
*
families. Sailaxmi Gandhi
We have attempted to provide an overview of the condition that Issues related to care and treatments of the patients in
your relative has. You may have additional questions. We urge you to rehabilitation facilities are diverse and varied. Few important issues
discuss with your mental health professionals regarding any questions are discussed here;
that you want to ask about your health. Non-Adherence:
Final words: Don’t be hopeless about your family member’s life One of the biggest challenges in treating mentally ill people is
just because he/she has ID. A large number of person’s with ID non-adherence. It is also one of the major causes for relapse and re-
have been able to live lives with support from their families, healthcare hospitalization. Patients do not necessarily follow the advice given to
professionals and their own efforts. them by health care professionals. A recent report by the World
_______________ Health Organization (WHO) revealed that 50% of patients with
chronic disease do not take their medication as prescribed. This
* Senior Resident, Department of Psychiatric Rehabilitation Services
* * Additional Professor, Department of Psychiatry mismatch between what is prescribed in terms of medication or
National Institute of Mental Health & Neurosciences, Bangalore. lifestyle changes and what patients actually do is commonly referred
to as non-compliance. Compliance, adherence, and persistence are
all terms commonly used in the literature to describe medication-
taking behaviour. However, Adherence has become the preferred
term, defined by the World Health Organization as “the extent to
which a person’s behaviour in taking medication corresponds with
agreed recommendations from a health care provider”. The word
‘adherence’ indicates active participation of the patient in the
treatment. Whereas, the term ‘compliance’ indicates passive
submission to the psychiatrist’s instructions.
Medication non-adherence, either may be deliberate or due to
reduced awareness. It can include;
• Failing to initially fill a prescription
• Failing to refill a prescription as directed
• Omitting a dose or doses
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• Taking more of a medication than prescribed including attitudes towards illness and treatment, belief system, social
problems like stigma, misconception, motivation, socio-demographic
• Prematurely discontinuing medication
factors like age, income, types of family, life style; and characteristics
• Taking a dose at the wrong time of therapeutic relationships including rapport, language and
• Taking a medication prescribed for someone else communication, quality of information, empathy and attitude are related
to each other. All these characteristics have influence on the treatment
• Taking a dose with prohibited foods, liquids, and other
adherence of mentally ill patients.
medications
The same has been presented in a pictorial form in the next page
• Taking outdated medications
(Figure.1);
• Taking damaged medications
Fig.1: Various factors affecting treatment adherence
• Storing medications improperly
• Improperly using medication administration devices (e.g.,
inhalers).
Importance of adherence:
In psychiatry, non-adherence or partial adherence is generally
estimated to be higher than in medical conditions and highest of all in
psychosis. If an individual stops using antipsychotic medication the
risk of relapse increases three to fivefold. Also risk of suicide has
been found to be 3.75 times higher in people with schizophrenia who
are non-adherent than in those who are adherent. The gap of treatment
for one month or less was associated with a 2.8 times risk of admission
to hospital in a year, whereas a gap of more than a month increase
the risk by nearly four times.
Factors affecting adherence- the bio-psychosocial perspective:
Many factors related to the patient, the illness, the medications,
the patient-therapist relationship, etc. contribute to adherence.
Disease characteristics like duration of illness, severity and
stages of illness; treatment characteristics like associated side-
effects, types of medications, duration of treatment, complexity of
dosing schedule and regimen, treatment cost; patient characteristics
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Factors Influencing treatment non-compliance in mentally ill deficits and lack of insight contribute maximum to non-
patients adherence.
Common reasons from the psychiatrist for non-adherence: • Side-effects of medicine: The benefits of medicine may only
become apparent over several weeks but adverse effects are
• Duration and complexity of drug regimen: Complex
present before the therapeutic effects. Adverse effects such
regimens such as multiple drug prescriptions at odd hours can
as extra- pyramidal side-effects, dystonia, sedation, sexual
lead to non-adherence. Simpler, less frequent dosing regimens
dysfunction, weight gain, skin pigmentation, etc contribute to
results in better compliance.
non-adherence.
• Poly-pharmacy: Increased number of medicines at the same • Cost of medicine: Higher cost can lead to medication non-
time or different timings can be perceived as confusing by the adherence.
mentally ill patient.
• Co-morbidity: Co-morbidity (associated illness) is likely to
• Providing inadequate patient education: Lack of proper increase the number of medications being taken by the patient,
information about mental illness and its treatment to the patient the number of physicians being visited and the number of
and care giver is one of the most important reasons for drug appointments to be kept. This makes the medication regimen
non-adherence among psychiatric patients. complex, costly and cumbersome for the patients to follow or
• Clinician-Patient Relationship: Failure to form a therapeutic incorporate into routine. Substance abuse is strongly associated
alliance with the patient is an important risk factor for non- with medication noncompliance among patients with
adherence. Clear and open communication plays a vital role schizophrenia.
here. It would be ideal to formulate a joint therapeutic plan. Reasons related to Patient:
• Not including family members in treatment plan: Adherence • Unawareness and lack of insight
is better when the therapist, patients and family members are
• Forgetfulness
partners in the treatment plan.
• Intentional non-adherence
• Inability to see the patient from a holistic perspective: The
therapist should consider the patient as a person with specific • Attitude and beliefs
life styles, occupations, social relationships, etc. which can • Autonomy and Control: People with mental illnesses may feel
affect adherence. that their lives are controlled by doctors, nurses and families
Reasons related to illness and treatment and these medicines too control their lives.

• Chronicity of illness Reasons related to Family:

• Psychopathology: Psychopathology has a link with the non- • Absence of a care taker or inadequate care taking
adherence of treatment among mentally ill people. The • Poor attitude and knowledge towards mental illness and
symptoms like grandiosity, acute psychosis, paranoia cognitive treatment
76 PSYCHIATRIC REHABILITATION PSYCHIATRIC REHABILITATION 77

• Illness in the Family: Chronic illness in other family members attitudes towards medical treatment in patients with
may lead to increasing financial loss. schizophrenia.
Psychosocial and environmental reasons: • Culture: Some cultures object to any mind altering medicine
or procedures on spiritual or religious grounds.
• Poor socio-economic status
Potential Solutions:
• Increased restriction on patient’s lifestyle: The treatment
strategies hampering the patients’ usual life style e.g. diet Basic communication
restrictions; change of usual daily activity timing, etc. may lead • Establish a therapeutic relationship and trust
to non-adherence.
• Identify the patient’s concerns
• Stigma related to mental illness: The patients embarrassed
• Take into account the patient’s preferences
by their mentally ill identity avoid going to the hospital. Stigma
towards patients with schizophrenia is also high, resulting in • Explain the benefits and hazards of treatment options
workplace difficulties, family rejection, follow-up defaulting and Strategy-specific interventions
treatment non-adherence.
• Adjusting medication timing and dosage for least intrusion by
• Lack of infrastructure: In developing countries like India, lack the psychiatrist
of manpower and health care facilities are the prime issues in
• Minimize adverse effects
health system. Lack of facilities and shortage of medical
professionals aggravate the situation of non-adherence. In terms • Maximize effectiveness
of resources, India has 0.25 beds per 10,000 population, 0.2 • Prompt treatment for the potential unwanted effects will be
psychiatrist, 0.05 psychiatric nurse, 0.03 clinical psychologist helpful.
and 0.03 psychiatric social workers per 1,00,000 population.
• Provide support, encouragement and follow-up.
• Social isolation: Lack of social support may also lead to
Reminders
treatment non-adherence.
• Consider adherence aids such as pill boxes and alarms
• Misconception related to mental illness: Some people believe
that mental illness is caused by sin done in the past life or by • Consider reminders via mail, email or telephone
some evil spirit which can be removed by the faith healer; • Home visits, family support, counselling
mental illnesses are untreatable, only marriage can cure mental
Evaluating adherence
illness, etc. All these misconceptions are common even among
literate people and lead to not coming for treatment or • Ask about problems with medication
discontinuing treatment in the mid-way. • Ask specifically about missed doses
• Religious belief: Religion and spirituality contribute to shaping • Ask about thoughts of discontinuation
78 PSYCHIATRIC REHABILITATION PSYCHIATRIC REHABILITATION 79

• With the patient’s consent, consider direct methods: pill counting, resentment and frustration can build within the patient and set
measuring serum or urine drug levels off a violent incident
Violence, Aggression and its Management 7. Invasion of privacy: Some-times the patient’s belongings
Violence is a form of aggression that is inclusive of threats (verbal/ may be taken or hidden by other patients which can cause
written/gestures) that imply harm, physical assault, damage to property irritation and set off fights
and sexual assault. Since persons with mental illness who are 8. Isolation by peer group: Patients attending PRS usually get
manageable are referred to Psychiatric Rehabilitation Services (PRS), to know each other and at times may tend to form groups
one may find less incidents of violence here than in an acute
barring entry to certain patients. This ostracization can lead to
psychiatric ward. Nevertheless, one needs to identify initial signs of
frustration building up and trigger aggression.
aggression so that it can be contained and major incidents prevented.
How does one identify impending violence?
What could be the possible causes?
One needs to be quite observant to cues which indicate building
Apart from the psychological, socio-cultural and biological theories,
there are other important yet most often ignored factors that contribute aggression. Some of these are:
for violence and aggression in an individual. Some of these are – 1. Hyperactivity (Pacing up and down, restlessness)
1. Communication skill of staff: Non-therapeutic 2. Increased tension: Clenched fist or jaw, rigid posture, tense
communication such as confrontation (when unwarranted), not facial expression, rapid breathing, hostile, cold and not possible
abiding by pre-set contracts, probing, challenging, etc. can lead to establish rapport
to unpleasant situations
3. Intense eye contact, glaring with suppressed anger
2. Unmet physical needs: Unsatisfied physical needs like hunger,
thirst, lack of sleep, etc. can cause aggression 4. Verbal threats

3. Attitude of staff: Authoritarian, punitive, rigid and non- 5. Verbal cues – ‘I am afraid I am losing control’
therapeutic attitudes can trigger violence 6. Tone of voice: Loud, high pitched. (Stony silence also can
4. Staff behaviour: Superior, tactless, disrespectful, non-caring, convey anger)
offhand behaviour can upset the patients General principles for management of violence:
5. Unstructured time: Improper structuring of available time
1. Establish rapport and emphasize co-operation
can allow the patient to be more pre-occupied with
hallucinations and delusions which can lead to aggression 2. Maintain the patient’s self-esteem and dignity (address by name
respectfully)
6. Change in surroundings: Changes if necessary should be
done after discussion with the patient so that he/she is prepared 3. The safety of the patient, other patients, caregivers and staff
and accepts the change. If not, psychological insecurity, is of the utmost concern
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4. Room doors should open outward and not be lockable from manner with limit setting can prevent eruption of violence in the PRS.
inside Structured environment with less stimulation when the patient is
excited can help the patient calm down.
5. Use de-escalation techniques to defuse the situation
Following tips may help:
6. Staff should monitor and control their own verbal and non-
verbal behaviour (avoid provocative or threatening behaviour) Identify and suppress trigger events. Keep the patient occupied
in activities of interest. Isolate patients with unacceptable behaviour
7. Be calm and avoid staring at the patient
with timeout prior to seclusion. If the group is large, divide into smaller,
8. Verbal de-escalation should be supported but not replaced by more manageable groups. Separate hostile parties. Call for help and
appropriate physical and/or chemical (drugs) intervention remain calm.
9. Do not move too close to the patient Behavioural strategies are mainly accelerative and decelerative
10. If the patient has potential weapons, never take it from the techniques. Techniques such as token economy (Specify targeted
behaviour with the patient. Reward with tokens that the patient can
patient, rather ask him/her to keep them down
use to buy items or privileges), activity programming (Provide
The continuum of violence management can be classified as: stimulating, interesting activities), social skill training, aggression
1. Preventive strategies replacement (divert by reading or watching TV, etc.), differential
reinforcement (constant rewarding of positive behaviour), and
2. Anticipatory strategies assertiveness training are accelerative.
3. Containment strategies Whereas, Limit setting (explain the rationale for the limit in a
1. Preventive strategies comprise of staff self-awareness, calm and respectful manner), time out (can be initiated by the patient
patient education and assertiveness training. One needs to be aware or the staff) and behavioural contracts (acceptable and unacceptable
of personal responses to expressions of anger, aware of personal behaviours to be outlined with consequences for breaking the contract
dynamics that may trigger emotions that are non-therapeutic and avoid specified) are decelerative techniques.
power struggles with the patient. Patients can be taught to manage Psychopharmacology is the use of medication to calm/lightly
anger in healthy, acceptable and adaptive ways such as deep breathing sedate the patient and reduce the risk to self and others. Lorazepam
exercises, taking a walk, positive self-talk, change of environment, (benzodiazepine), haloperidol (antipsychotic) intravenously or
writing about his/her feelings, counting up to 50 and reverse, relaxation intramuscularly are commonly used. ECT (electroconvulsive therapy)
exercises, etc. Role plays can be used to teach the patient is used when there is high risk for homicide/suicide, unsatisfactory
assertiveness skills. Patients can return demonstration through role response to drug therapy, when drugs are contra-indicated or have
plays and get feed-back from the staff. serious side effects and when there is a need for rapid response
2. Anticipatory strategies: comprise of communication, owing to the severity of the condition.
environmental change, behavioural actions, psychopharmacology and 3. Containment strategies: Crisis management, seclusion and
ECT. Communicating on time and in the appropriate, therapeutic restraints are containment strategies. Crisis management has already
 82 PSYCHIATRIC REHABILITATION PSYCHIATRIC REHABILITATION 83

been discussed in this book. Seclusion is the involuntary confinement blood supply), asphyxiation, sudden death and hence, need to be used
of a patient alone in a room for a specified period of time. A restraint with the utmost caution and frequent monitoring.
is a mechanical or physical device that is used to immobilize a patient
What should one do in the event of violence?
or extremity. Seclusion and restraints are not punitive and used as a
last resort when all measures fail. Acting quickly is of primary importance. The team leader (any
member of the PRS) should be calm, think on their feet, take
Seclusion and restraints are used:
appropriate decisions, utilize available manpower and resources and
• To prevent imminent harm to the patient and others (only if organize a plan of action effectively keeping in mind the safety of the
other means are not effective or appropriate) patient, other patients and staff as a matter of concern. The entire
• To prevent serious disruptions of the treatment program or team should synchronize and work in co-ordination. In case additional
significant damage to the environment help is needed, one has to summon assistance.

• As a part of an ongoing behaviour treatment program • Shift other patients in the vicinity

• At the patient’s request for seclusion • Help should not be taken from other patients

Common guidelines to be followed while using seclusion and • Speak calmly to the patient and state limits/expectations
restraints: • Do not threaten the patient
· The patient has to be informed about the reason for seclusion/ • Use simple, clear words and state one instruction at a time
restraints
• If the patient has a weapon, don’t try to remove it. Ask the
· No dangerous objects should be with the patient during the patient to keep the weapon on the ground
seclusion period
• As one keeps the patient engaged by talking to him/her, other
· Restraints should not be tight – staff has to check periodically
staff can approach from behind, cover the patient’s head with
· Physical needs have to be attended to a blanket or bed sheet. If the patient has a weapon, it can be
· The seclusion room should be free of stimuli and safe then removed. Restraints can be then applied to the limbs.

· Following each episode of seclusion/restraint use, staff should • Support and hold at large joints (small joints can easily get
talk to the patient about the episode and allow ventilation dislocated /fractured).

· The patient should not be reminded about his stay in the • If necessary, the patient can be sedated
seclusion room or that he/she had been restrained • Once calm, the restraints can be removed and the patient
· Seclusion or restraints should never be used as threats to walked to the seclusion room
intimidate the patient • As the experience of seclusion or being restrained can be
Restraints have associated risk of nerve injury, ischemia (reduced scaring, reassure the patient
• · Attend to the patient’s needs
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• Monitor frequently Characteristics of Crisis

• Once calm, the patient can be brought out of seclusion • Crisis occurs in all individuals at one time or the other.
• Encourage the patient and other patients also to ventilate • Crises are precipitated by specific events of actual or perceived
• Psychological autopsy (i.e. discussion with the team members losses, threats of losses.
following the incident of violence about better ways of • Crisis is personal by nature. What may be considered as a
managing the situation or whether it could have been handled crisis situation for one, may not be a crisis for another.
in a better manner, etc.) is important
• Crisis is acute, not chronic and will be resolved in one way or
• Family members (if present) emotions and fears should also another within a brief period.
be addressed
• There is a disorganization of biological, cognitive, emotional
• Ongoing re-integration of the patient back into the milieu is and behavioral experiences.
important
• The ability to solve problems reduces when in a crisis.
Conclusion: A violence incident in the PRS should always be
reported to the team members so that appropriate changes in the Types of Crisis
treatment and rehabilitation process can be initiated. The family • Situational Crisis: Results from an external event or
members also can be involved in violence management so that they environment influences that upsets the individual. Eg. A
feel less helpless in the home environment when confronted with diagnosis of terminal illness, an accident
similar incidents.
• Maturational Crisis: Are developmental events along with
Crisis Intervention growth and development. Eg. Erik Erickson’s developmental
Defining Crisis tasks – transition from being a student to an employee, entering
“Crisis is a psychological disequilibrium in a person who confronts marriage, becoming a parent, beginning of menopause etc.
a hazardous circumstances that for him constitutes an important • Adventitious Crisis: Is an accidental, uncommon and
problem which he can for the time being neither escape nor solve unexpected tragedy that disrupts the entire community. Eg.
with his customary problem solving resources” (Caplan, 1964) Fire, Flood, Earthquake
The aim of crisis intervention is to: • Socio-Cultural Crisis: Arises from cultural values that are
a) Reduce distress. embedded in the social structure. Eg. Job loss due to deviant
acts, behavioural problems, etc.
b) Help to solve problems.
Mental health crises include:
c) Avoid maladaptive coping strategies – eg: self-harm, taking
alcohol/drugs • Suicidal behaviour or intention
d) Improve problem-solving strategies. • Panic attacks/extreme anxiety
86 PSYCHIATRIC REHABILITATION PSYCHIATRIC REHABILITATION 87

• Psychotic episodes (loss of sense of reality, hallucinations, disorganization of the individual with drastic results often occurs.
hearing voices) Anxiety may reach panic levels. Cognitive functions are
• Other behaviour that seems out of control or irrational and disordered. Emotions are labile and behaviour may reflect the
that is likely to endanger yourself or others. presence of psychotic thinking.
Principles of Crisis Intervention
These types of situation can also be described as ‘acute’ and
require access to ‘acute’ services. • Even a well-adjusted person faces crisis. Stress tolerance varies
among individuals.
Other kinds of mental health crisis:
• Emotional crisis are self-limiting events and resolution takes
Many people may experience one or more episodes of mental
place within 4-6 weeks.
distress in their lifetime that they would identify as a crisis, but which
does not require crisis or acute mental health services. If a person is • Individual in crisis use coping strategies that were used during
experiencing emotions or behaviours that are painful or hard to manage earlier crisis.
(e.g. depression, intense loss or bereavement, or self-harm) he might
• Every crisis management is an additional learning.
see this as a crisis. He may still need to access services that he does
not need at other time, to help him resolve the crisis or to support, • Adaptive crisis resolution in the past interferes with the crisis
until it has passed. resolution process of the present.

Phases of Crisis • Previous adaptive crisis resolutions are not useful all the time

• Phase I: The individual is exposed to a precipitating stressor. • Inherent in every crisis, is an actual or an anticipated loss to
Anxiety increases. Previous problem solving techniques are the individual that must be reconciled. Every crisis resolution
employed is an interpersonal event.

• Phase II: If the problem is not solved, anxiety increases. The • Effective crisis resolution prevents future crisis.
individual feels a great deal of discomfort, becomes weak and Techniques of Crisis Intervention
vulnerable. Coping techniques that have worked in the past
• Abreaction: It is the release of feelings that takes place as
are attempted.
the individual talks about emotionally changed areas.
• Phase III: All possible resources - both internal and external
• Clarification: It is encouraging the client to express more
are called on to resolve the problem. The individual may try to
clearly the relationship between certain events in his life.
view the problem from a different perspective or even overlook
certain aspects of it. New problem solving techniques may be • Suggestion: It is influencing the client to accept an idea or
used. belief that he will feel better.
• Phase IV: If resolution does not occur, tension mounts beyond • Manipulation: It is using the client’s emotions, wishes or values
the individual’s threshold and reaches breaking point. Major to his benefit in the therapeutic process.
• Re-inforcement behaviour: It is giving the client positive
88 PSYCHIATRIC REHABILITATION PSYCHIATRIC REHABILITATION 89

responses to adaptive behaviour. to a specific problem in a specific client. Eg: One to one
• Support of defenses: Encouraging the use of healthy, adaptive counselling at the time of labor pain
defenses and discouraging unhealthy or maladaptive coping Performing crisis intervention
behaviour. The earliest stages of crisis therapy are concerned with the
• Raising self-esteem: It is to help client regain feelings of clarification of the patient’s problem. The therapist then encourages
self-worth. the patient to express their emotions around the crisis - Eg, grief. The
• Exploration of solutions: It is examining alternative ways of patient is encouraged to seek support from their social network of
solving the immediate problems. friends and family. The patient is asked to discuss their coping
mechanisms and the therapist encourages appropriate methods.
Process of Crisis Intervention Sometimes these could be seeking social support, change of
Goal: To resolve immediate crisis. Restore and bring the level of environment, matching capabilities with available job offers, use of
functioning to the pre-crisis state. humour, meditation, etc.
Assessment: Alternative problem-solving strategies are generated by the
• Identify the precipitating event. patient and their potential consequences discussed.

• Explore the client’s perception of the event. The therapist attempts to discourage inappropriate beliefs and
coping methods, either by direct suggestion or using cognitive methods
• Recognize the nature and strength of the client’s support
such as:
system.
a) Keeping a diary of events, and their surrounding thoughts and
• Find out the client’s previous strengths and coping mechanisms.
feelings.
Intervention:
b) Practising and testing new behaviours in a safe, protective
• Environmental manipulation: It is directly changing the client’s setting.
physical environment or psychological situation.
People with severe mental illness who are in a crisis often need
• General support: Extending the psychological and physical hospital admission. If admission is not considered necessary or
assistance to solve problems. Eg: Leg amputee patient is appropriate, urgent liaison with Community Mental Health Services
encouraged for mobilization with warmth, acceptance, is essential.
empathy, caring and reassurance.
De-escalation techniques that may help family members resolve
• Generic approach: It is to reach high-risk individuals and a crisis include the following principles:
implement mapped out solutions to reach pre-crisis stage. Eg:
Intervention to disaster victims. i. Keep voice calm

• Individual approach: It is application of specific intervention ii. Use short sentences

90 PSYCHIATRIC REHABILITATION PSYCHIATRIC REHABILITATION 91

iii. Listen to their story 5. What can be done to reduce family stressors?
iv. Offer options instead of trying to take control Trends in Crisis Intervention
v. Remain calm, avoid overreacting • On-sight crisis counselling.
vi. Move slowly • Mobile out reach.
vii. Don’t argue or shout • Telephone counselling and hot lines. Eg: Suicide prevention
viii. Express support and concern through telephone counselling, Battered Women’s Hot line.
ix. Keep stimulation level low • Disaster response and critical incident stress debriefing.
x. Avoid eye contact • Group work.
xi. Be patient and accepting • Health education.
xii. Announce actions before initiating them Conclusion:
xiii. Give them space, don’t make them feel trapped A mental health crisis may be a sign that your care or treatment
Often a trained mental health professional can help a family de- is not working and needs to be changed. It can have serious
escalate a crisis before it occurs. consequences if not managed well. But crises can have good outcomes
if handled well. Educating family members about the techniques which
Prevention:
are effective in managing or preventing crisis will be more beneficial
The best way to prevent a crisis is to have a treatment plan that _______________
works and is followed. Family members can prevent a crisis by * Assistant Professor, Department of Nursing
noting changes in behaviours, documenting behaviours by keeping a National Institute of Mental Health & Neurosciences, Bangalore.

journal, making notations on a calendar or listing commonly occurring

behaviours. It is important to remember to note changes and early
warning signs because they might be an indicator that a crisis could
occur.
In order to prevent a crisis, it’s also important to note
1. What situations have led to a crisis in the past?
2. What has worked to help reduce stress or to avoid a conflict in
earlier similar instances?
3. What steps can be taken to keep everyone safe and calm?
4. Who can be called for support in a crisis or to help calm the
situation?
92 PSYCHIATRIC REHABILITATION PSYCHIATRIC REHABILITATION 93

References: LEGISLATIONS GOVERNING PEOPLE

• John McGovern Management of Risk in Psychiatric WITH MENTAL ILLNESS
Rehabilitation. The Psychologist, September 1996, 405- *
Sivakumar T,
408 **
Nirmala.B.P.,
• Violence: The short-term management of disturbed/violent ***
Usha Kiran.K.T
behaviour in in-patient psychiatric settings and emergency
Introduction
departments. Commissioned by the National Institute for
Health and Clinical Excellence (NICE): Published by the The current chapter focuses on legislations governing mental illness
Royal College of Nursing,20 Cavendish Square, London in India. The key Indian legislations directly or indirectly related to
W1G 0RN ;February 2005. Publication code: 003 mental health, disability and welfare of persons with mental/psychiatric
017;ISBN: 1-904114-21-0 disabilities are listed in Table 1.

• Victoria A. Coburn, Mark B. Mycyk, Physical and Table 1. Indian legislations directly or indirectly related to
Chemical Restraints. [Link] mental health, disability and welfare of persons with mental/
content/uploads/2010/12/Physical-and-Chemical- psychiatric disabilities
[Link]
• Robert I. Simon, Kenneth Tardiff .Textbook of Violence
and Management. American psychiatric publishing; 2008.
• Carol Renkneisl, Holly Skodol Wilson, Eileen Trigoboff.
Contemporary Psychiatric Mental Health Nursing. New
Jersey: Pearson Education; 2004.
• Mary Ann Boyd Psychiatric Nursing: Contemporary
Practice, 4th edition. China: Lippincot Williams and
Wilkinsons; 2008.
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This chapter will focus on legal aspects pertaining to mental illness on the management of their property and protection of human rights
in Mental Health Act, Persons With Disabilities Act, Narcotic Drugs were included. The act prohibits any research on mentally ill subjects
and Psychotropic Substance Act, Income Tax Act, National Trust without proper consent. The act has provisions to provide legal aid to
Act. poor mentally ill prisoners at state expenses.
Need for a separate law for mental illness There are no provisions for rehabilitation and post discharge care
of mentally ill in the act. A person admitted to a mental hospital is
Separate laws for mental illness are necessitated by the following
labelled mad or insane by the society. There are no provisions in the
factors;
act to educate the public about myths and misconceptions regarding
• Mental illness is different in nature from physical illness. mental illness. The emphasis is on hospital admission and treatment.
• Apart from the patient, mental illness affects the family and No provision exists for home treatment. This increases stigma and
adds to cost of treatment. The act has retained criminal flavour of
society as well.
earlier act by keeping the power of the criminal court to exert its
• A mentally ill person may not have insight into the illness and control over admissions and discharge of non-criminal mentally ill
may be unable to make rational decisions due to the illness. persons.
• Fundamental rights of mentally ill persons can be violated Persons with Disability Act 1995
because of the nature of psychiatric disorder.
Person with a disability means a person suffering from not less
The Mental Health Act (1987) than 40 percent of any disability as certified by a medical authority.
The Mental Health Act (1987), which came into force in 1993, is Mental illness was included as seventh disability in PwD act 1995
an act to consolidate and amend the law relating to the treatment and after lobbying by government institutes and NGOs. According to this
care of mentally ill persons, to make better provision with respect to act, “mental illness” means any mental disorder other than mental
their property and affairs and for matters connected to it. It was a retardation. Disabilities covered in the Act are: blindness, low vision,
leprosy cured, hearing impairment, loco-motor disability, mental
significant advance over the earlier Indian Lunacy Act 1912.
retardation, and mental illness.
Offensive terminologies in earlier act like lunatic and criminal
The Central Co-ordination Committee and Executive
lunatic were replaced with mentally ill person and mentally ill prisoner
Committee
respectively. According to the act, a mentally ill person is defined as
a person suffering from a mental disorder, other than mental retardation, 1. The Central Co-ordination Committee (CCC): The
needing treatment. The act has provisions and safeguards to ensure Central Government shall constitute a Central Co-ordination
that persons are not unnecessarily detained under the act. Procedure Committee (CCC), headed by the Minister of Social Justice &
for admission and detention of mentally ill persons are laid out in the Empowerment. CCC consists of 39 persons: 24 will be official
act. Central and State Mental Health Authorities were created for members and 15 nominated by the Government will represent
licensing and supervising psychiatric hospitals to safeguard the NGOs and associations concerned with disabilities. Atleast one
interests of the mentally ill person under one authority. New chapters woman and one person from Scheduled Caste or Scheduled
96 PSYCHIATRIC REHABILITATION PSYCHIATRIC REHABILITATION 97

Tribe is to be included. The term of all the members will be for Indian Disability Evaluation and Assessment Scale (IDEAS, 2002)
three years. The Committee shall meet once every six months. was developed by the Rehabilitation Committee of the Indian
Important function of the Central Coordination Committee Psychiatric Society (IPS) through a Task Force and was gazetted on
shall be the following: 27th February 2002 to quantify mental disability and converting
disability into percentage as required by the act. IDEAS can be used
a) Review and coordinate the activities of Government and NGOs.
only for evaluation of four mental illnesses: Schizophrenia, Bipolar
b) Development of National Policy. Affective Disorder, Obsessive Compulsive Disorder and Dementia.
c) Advise the Central Government on the formulation of policies, Duration of illness should be at least two years.
programs, legislation and projects. There were objections from other disability groups that illness
d) Advocacy with national and international organizations with a and disability were different entities. It was argued that mental illnesses
view to provide for schemes and projects for the disabled in included transient and chronic conditions leading to heterogeneity and
national and international plans and programs. inequity. The Amendment Committee 1999 examined this issue in
detail and from various perspectives before concluding that it must
e) Review donor funding policies from the perspective of their be retained in the Act.
impact on person with disabilities.
The act provides for the following measures pertaining to PwD
f) To ensure barrier free environment. due to mental illness;
g) Monitor and evaluate the impact of policies and programs. • Constitution of central and state coordination committee for
The Central Coordination Committee will be bound by such disability related matters
directions in writing as the Central Government may give it. • Mandatory for government to provide free education to disabled
2. The Central Executive Committee (CEC): The Central children till 18 years of age
Executive Committee shall carry out the decisions of the • Scholarship for PwD students; books, uniforms, transport and
Central Coordination Committee. CEC will consist of 23 other facilities for PwD children
persons, including five persons concerned with disability. The
Executive Committee shall meet at least once in every three • Appropriate Governments and local authorities to make
months. schemes and programmes for non-formal education

The State Coordination and Executive Committee • All Government educational institutions and other government-
aided educational institutions shall reserve 3% seats for PwD
Each state shall appoint a State Coordination Committee,
consisting of 23 official and five non-official members. The State • 3% reservation in poverty alleviation schemes
Executive Committee will have 13 official and 5 non-official members. • Special employment exchange for PwD
The terms conditions and functions of the State Committee shall be
the same as those of the Central Committee.
• Schemes for ensuring employment of PwD
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• Incentives to employers in public and private sectors to ensure rehabilitation program, Half Way Home for Psycho-Social
that at least 5% of their work force is composed of PwD Rehabilitation of Treated and Controlled Mentally Ill Persons
• Aids and appliances to PwD etc.

• Schemes for preferential allotment of land for PwD • Swarnajayanti Grama Swarojagar Yojna (SGSY), Indira Awaas
Yojana (IAY), National Rural Employment Guarantee Act
• In Government establishment, an employee who acquires a
(NREGA) and Sampoorna Grameen Rozgar Yojana (SGRY)
disability during his service cannot be dispensed with nor can
provide 3% reservation/benefits for PwD.
his/her rank be reduced
• Under the Scheme of National Scholarships for Persons with
• Promotion cannot be denied on the basis of disability
Disabilities, every year 500 new scholarships are awarded.
• Promotion and sponsorship of research for rehabilitation and Students with 40% or more disability whose monthly family
job identification income does not exceed Rs. 15,000/-are eligible for scholarship.
• Establishment of institutions for persons with severe disability A scholarship of Rs. 700/- per month to day scholars and Rs.
(>80% disability) 1,000/- per month to hostellers is provided to the students
pursuing Graduate and Post Graduate level technical or
• Chief Commissioner and State Commissioners for PwD with
professional courses. A scholarship or Rs. 400/- per month
powers of a civil court to co-ordinate work, monitor utilization
of funds and take steps to safeguard the rights and facilities of today scholars and Rs. 700/- per month to hostellers is provided
PwD for pursuing diploma and certificate level professional courses.
In addition to the scholarship, the students are reimbursed the
• Financial assistance to NGO’s working for rehabilitation of
course fee subject to a ceiling of Rs. 10,000/- per year.
PwD
• Scheme of National Awards for Empowerment of Persons
• Insurance scheme for PwD
with Disabilities.
• Unemployment allowance to PwD registered with the Special
• National Handicapped Finance and Development Corporation
Employment Exchange for more than two years and who could
(NHFDC) provides loans on concessional terms to PwD.
not be placed in any gainful occupation
• Government will pay employer’s contribution to the Employees
• Punishment for fraudulently availing PwD benefits
Provident Fund and Employees State Insurance for the first
Schemes/Programs under PwD act are three years for PwD employed in private sector with disability
• Deendayal Disabled Rehabilitation Scheme to promote covered under PwD Act (1995) /National Trust Act (1999)
Voluntary Action for Persons with Disabilities (Revised DDRS with monthly wage upto Rs 25000/month. The scheme would
Scheme). Grants in aid are provided to NGOs for vocational be applicable to all the employees with disabilities, who are
training centres, sheltered workshops, legal literacy, home based appointed on or after 1.4.2008.
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• Aids and appliances are provided to PwD under the Scheme Non-discrimination
of Assistance to Disabled Persons for Purchase/Fitting of Aids/ The Act envisages that Government transport shall take special
Appliances (ADIP). measures to adapt their facilities and amenities so as to permit easy
• Setting up of Composite Regional Centres for Persons with access to person with disabilities.
Disabilities (CRCs) and District Disability Rehabilitation
All authorities shall within their capacity, provide auditory signals
Centres (DDRCs).
along red lights and crossings, constructions shall be designed so as
• Pilot project for creation of awareness on prevention and early to enable wheel chair users, and engraving on zebra crossing for the
detection and intervention of various types of disabilities has blind should be done. Buildings shall be constructed with ramps and
been taken up. other necessary features.
• Models to promote awareness about accessibility features in No employer shall terminate an employee who acquires a
public buildings. disability during service. No employer shall also deny promotion to
Prevention and early detection of disabilities an employee on grounds of disability.
Within the limits of economic capacity and development, Affirmative Action
appropriate Government and local authorities concerned, with a view The Government shall provide aids and appliances to persons
of preventing the occurrence of disabilities, shall with disabilities. The Government shall also provide land at
a) Undertake surveys, investigation and research concerning the concessional rates to PwDs for housing, business, establishing special
cause of occurrence of disabilities. recreation centres, special schools, research centres and factories
by entrepreneurs with disabilities
b) Promote various methods of preventing disabilities.
Employment
c) Screen all children at least once in a year for identifying at risk
cases. The government shall reserve atleast 3% posts in Government
jobs for persons with disabilities as follows:-
d) Provide facilities to trained staff at the primary health centres.
1. Blindness or low vision 1%
e) Sponsor awareness campaigns and disseminate information
for general hygiene, health and sanitation. 2. Hearing impairment 1%
f) Take measures for prenatal and postnatal care of mother and 3. Locomotor disability or cerebral palsy 1%
child.
If in any year, vacancy reserved for disabled person cannot be
g) Educate the public through pre-schools, schools, primary health filled, then it would be carried over to next year, thereafter people
centres, village level workers and anganwadi workers. with other disabilities can be given employment. Finally, if there is no
h) Create awareness amongst masses through T.V., Radio and suitable disabled person, then only a person other than a person with
other mass media on the causes of disabilities and its prevention disability can be given employment.
Special employment exchange for disabled persons should be set up.
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The Government shall formulate schemes for ensuring The government shall promote research to develop assistive
employment of persons with disabilities including training, relaxation devices to give children with disabilities equal opportunities in
of upper age limit etc. education.
All Government educational institutions and those receiving aids The government shall present a comprehensive education scheme
from the Government shall reserve not less than 3% seats for persons including transportation, barrier free environment and grievances
with disabilities. Not less than 3% of all poverty alleviation schemes redressal forum.
shall be reserved for persons with disabilities. Government shall within Research and manpower development
their economic capacities frame schemes to give incentives to
employers in public and private sectors to ensure that atleast 5% of The government shall promote and sponsor research to prevent
their workforce is composed of persons with disabilities. disabilities, rehabilitate the disabled, develop assistive devices, identify
jobs and develop pro-disabled structural features in factories and
Education offices.
Every child with disability should have access to free and adequate Limitations of the act:
education till the age of 18. Students with disabilities have to be
integrated into normal schools, set up of special schools in government • Low Awareness of act.
and private sectors and equip these special schools with vocational • A number of commitments in the act are subject to the “limits
training facilities. of economic capacity and development” of the relevant
The Government shall introduce schemes for non formal education authorities. The Act does not outline any process to determine
of children who have discontinued their education after 5th class, appropriate level of policies and interventions which might be
conduct special part time classes for functional literacy in the age expected at different levels of economic development. As there
group of 16 and above and provide each child, free of cost special is no process to benchmark reasonable performance by states
books and equipments needed for this or her education, including on the contingent entitlements of the Act, courts have become
education in open schools and universities. the main point of reference to enforce performance by
governments on matters pertaining to PwD.
The government shall set up teachers training institution to develop
teachers training programmes specialising in disabilities so that • The act has an administratively-driven policy and delivery model
mechanism. There is limited role for NGOs/DPOs (Disabled
requisite trained manpower is available to run special and integrated
Persons Organization), civil society and PwD themselves.
schools for children with disabilities.
DPOs are not mentioned in the Act at all. There is no obligation
The government shall provide to such children transportation for governments to consult directly with PwD. The act assumes
facilities, remove architectural barriers from educational institutions that disability NGOs will act as a conduit for PwD.
imparting vocational training and education, provide books, uniforms
and other materials to disabled children attending schools, grant
• The act does not have reservation for PwD due to mental
illness.
scholarships and restructure curriculum for the benefit of students
with disabilities. • PwD commissioner has weak powers.
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Disability is a multisectoral field and there are challenges in convictions. Among other activities, this fund is to be used for
intersectoral coordination. Poor budgetary allocation to PwD, lack of rehabilitating addicts.
staff in PwD commissioner office and political commitment are major
The act also empowers the Government to establish centers for
challenges in implementation.
identification, treatment, education, aftercare, rehabilitation and social
Income Tax Act reintegration of addicts.
Under section 80U, there is an exemption of income tax deduction United Nations Convention on the Rights of Persons with
for the amount of Rs.50000 for PwD (e”40% disability) and Disabilities (UNCRPD)
Rs.1,00,000 for persons with severe disability (e”80% disability). A According to UNCRPD (2007), “Disability is an evolving concept,
similar exemption may be availed by family member(s) of Hindu and that disability results from the interaction between persons with
united family under section 80DD for expenditure incurred in relation impairments and attitudinal and environmental barriers that hinders
to maintenance/treatment or for investing in a particular scheme of full and effective participation in society on an equal basis with others”
LIC for benefit of the dependent PwD. A certificate from prescribed
Persons with disabilities include those who have long-term physical,
medical authority is needed for availing the benefits.
intellectual or sensory impairments which in interaction with various
The Government also provides incentives to private sector barriers may hinder their full and effective participation in society on
employers for providing employment to PwD. an equal basis with others.
Narcotic Drugs and Psychotropic Substance Act (NDPS Act Approximately 10% of the world’s population are persons with
1985)
disabilities (over 650 million persons). Approximately 80% of them
An addict convicted under the NDPS act may be released on are living in developing countries. Though pre-existing human rights
probation after signing a bond with or without sureties, for detoxification conventions offer considerable potential to promote and protect the
or de-addiction from a hospital or an institution maintained or rights of persons with disabilities, this potential was not being tapped.
recognized by the Government. The conviction would stand and the The Convention sets out the legal obligations on States to promote
sentence remains in abeyance to enable the offender to report back and protect the rights of persons with disabilities. It does not create
on successful completion of de-addiction treatment within one year. new rights. The purpose of Convention is to promote, protect and
The court may direct the release of the offender after successful ensure full and equal enjoyment of all human rights and fundamental
completion of de-addiction treatment and abstaining from the freedoms by all persons with disabilities, and thus promote respect
commission of any offense under the act for three years. On failure for their inherent dignity. (UNCRPD, 2007).
to do so, the offender would have to serve the sentence.
Convention Timeline (History)
Under the act, the Central Government has constituted ‘National
• Adoption by the United Nations General Assembly – 13th
Fund for Control of Drug Abuse’ with government and public
December 2006
contributions and also with the sale of proceeds of forfeited property
derived from or used in illicit traffic with action predicated on criminal • Opened for signature – 20th March 2007
106 PSYCHIATRIC REHABILITATION PSYCHIATRIC REHABILITATION 107

• Entry into force – 3rd May 2008 • Respect for privacy (Article 22)
• First conference of states parties – 31 st October to 3 rd • Respect for home and the family (Article 23)
November 2008
• Right to education (Article 24)
• Second Conference of States Parties – 2nd to 4th September
• Right to health (Article 25)
2009
• First session of the Committee on the Rights of Persons with • Right to work (Article 27)
Disabilities – 23rd to 27th February 2008 • Right to adequate standard of living (Article 28)
Uniqueness about the Convention • Right to participate in political and public life (Article 29)
• Both a development and a human right instrument • Right to participation in cultural life (Article 30)
• A policy instrument which is cross- disability and cross-sectoral Implications
• Legally binding • Legislative and administrative measures
• Persons with disabilities are not viewed as ‘ objects” of charity, • Modify or abolish existing laws, regulations and customs and
medical treatment and social protection; rather as “ subjects” practice
with rights
• Special provision in all policies and programmes
• The Convention gives universal recognition to the dignity of
persons with disabilities • Refrain from any act or practice that is inconsistent with the
present convention
Rights of persons with disabilities as per the Convention
• Appropriate measures to eliminate discrimination by person,
• Equality before the law without discrimination (Article 5)
organization private enterprise
• Right to life, liberty and security of the person (Articles 10-14)
• To undertake and promote research and development
• Equal recognition before the law and legal capacity (Article
• To provide information to PwD
12)
• Freedom from torture (Article 15) • Training of professionals
The National Trust Act
• Freedom from exploitation, violence and abuse (Article 16)
The National Trust for the Welfare of Persons with Autism,
• Right to respect physical and mental integrity (Article 17)
Cerebral Palsy, Mental Retardation and Multiple Disabilities Bill, 1999
• Freedom of movement and nationality (Article 18) was passed by the Parliament on 15th December 1999 and was given
• Right to live in the community (Article 19) assent by the President of India on 30th December 1999. The passing
of the National Trust Act has thus fulfilled the objective of having a
• Freedom of expression and opinion (Article 21)
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separate legislation for the welfare and rehabilitation needs of persons person for the benefit of persons with the above disabilities in
with mental retardation and other developmental disabilities. general and for furtherance of the objectives of the Trust in
particular.
Objectives
• The Board shall receive from the Central Government such
The objectives of the National Trust are:
money as may be considered necessary in each financial year
• To enable and empower persons with disability to live as for providing financial assistance to registered organizations
independently and as fully as possible within and as close to for carrying out any approved programme.
the community to which they belong. • It will be necessary for all registered parents’ association or
• To strengthen facilities to provide support to persons with voluntary organizations or associations of persons with
disability to live within their own families. disabilities whose main object is promotion of welfare of persons
with disability to register themselves with the Board. The Broad
• To extend support to registered organizations to provide need has laid down a procedure for registration. Only the registered
based services during the period of crisis in the family or person organization would be entitled to receive assistance from the
with disability. Board.
• To deal with problems of persons with disability who do not Local Level Committees
have family support. • The Local Level Committees to be constituted in all districts
• To promote measures for the care and protection of persons of the country is one of the most important functions of the
with disability in the event of death of their parent or guardian. Trust. The Local Level Committees will consist of an officer
of the rank of District Magistrate Commissioner of a District
• To evolve procedure for the appointment of guardians and with two other members - one of them a representative of a
trustees for persons with disability requiring such protection. registered organization and the other person with disability.
• To facilitate the realization of equal opportunities, protection One of the main functions of the Local Level Committee is to
of rights and full participation of persons with disability. appoint a guardian for a person with disability as per the
procedure laid down in the Act.
• To do any other acts which are incidental to the aforesaid
• The Local Level Committee will have to fulfil at other tasks
objects.
entrusted to it by the Board from time to time to achieve the
Powers and Duties of the Board objective of the National Trust Act.
• The Board is entitled to receive a one-time contribution of Rs. _______________

100 crores for a corpus from the Central Government which it

* Assistant Professor, Department of Psychiatric and Neurological Rehabilitation,
will utilize to provide adequate standard of living for persons (Psychiatric Rehabilitation Services),
* * Associate Professor, Department of Psychiatric Social Work,
with the above categories of disability. ***Junior Research Fellow (DST funded Project on ASD) Department of Child and
Adolescent Psychiatry,
• The Board will receive bequest of movable property from any National Institute of Mental Health & Neurosciences, Bangalore.
110 PSYCHIATRIC REHABILITATION PSYCHIATRIC REHABILITATION 111

References: FAMILY INVOLVEMENT IN PSYCHIATRIC

• UN Convention on the Rights of Person with Disabilities REHABILITATION
(2007). Retrieved 28 October 2010, from [Link]/ *
B. P. Nirmala,
disability.
**
Faseela Jaleel
• Frequently asked questions. Retrieved 7 November 2010,
from http:[Link]. Introduction:
• India. The mental health act (1987). Retrieved 7 Family plays an important role in the rehabilitation and
November 2010, from [Link] reintegration of a person with disability back into the family and
[Link]. community. Traditionally too, in India, families are the major support
systems for anyone who faces physical or mental challenges. They
• The persons with disabilities equal opportunities, protection
accommodate the person with disability and provide physical,
of rights and full participation act (1995).
emotional and financial support.
Family has been an essential part of the mental health care
programmes. The emphasis on the family as the single most important
source of care is fairly unique for India and contrasts with the emphasis
on professional and institutional mental health care in developed
countries. Compared to the western countries, India has limited social
security benefits and government run rehabilitation facilities for the
mentally ill. Hence, families are the only support system that
contributes and facilitates recovery in a person with mental illness.
Unlike other disabilities, psychiatric disability creates a lot of stress in
the family due to the person’s impaired basic and independent activities
of daily living, poor social and occupational functioning, cognitive
deficits, and other behavior which disrupts the family. There are
instances where the other family members leave their work and stay
at home to take care of the affected member. It affects the emotional
and physical health of the caregiver too. At this stage, psychiatric
rehabilitation is an important option for the families to help the patient
get back to life.
Mental illness in a family member, especially for those living in
poverty leads to the extreme marginalization of the individual and the
112 PSYCHIATRIC REHABILITATION PSYCHIATRIC REHABILITATION 113

family, as both these hamper the ability to be productively engaged, The caregivers play an important and difficult role, especially
and to access necessary resources. Person With Mental Illness’ when their wards have severe mental illness. Community-based
(PWMI’s) initiative is affected by internal factors (within the individual) approach places more demands on family caregivers. The provision
and external factors (due to lack of specific support facilities). The of assistance and support by one family member to another is a regular
social stigma further blocks community support and access to and usual part of family interactions, and is in fact a normal and
resources. Poverty and gender issues compound these dynamics. pervasive activity. Thus, care giving due to chronic illness like mental
Being mentally ill and a female, the family’s investment for care is illness and disability represents something that, in principle, is not
likely to be less and so also other support needed for recovery. The very different from traditional tasks and activities rendered to family
consequences are unhappy lives of individuals sometimes leading to members. This is especially true for women. Across cultures, women
extreme crisis, poor coping abilities of the family, lost productivity have traditionally shouldered a disproportionate amount of family care
and stress in the community. giving responsibility. The difference, however, is that care giving in
chronic illness often represents an increase in care that surpasses
Because of the paucity of mental health care, families have been
the bounds of normal or usual care. Care giving in mental illness
given more responsibilities to provide care to their mentally ill family
involves a significant expenditure of time and energy over extended
member, whether it was by choice or our cultural influence or due to
periods of time, involves tasks that may be unpleasant and
the lack of facilities, it is difficult to conclude, though there is some
uncomfortable and is often a role that had not been anticipated by the
evidence to support that family involvement in care was and continues
caregiver. When these unanticipated roles are incongruent with
to be a preference of families. It is unfortunate that the experiences
stereotypical gender expectations (e.g., when a male caregiver must
of the families have not been adequately studied and the strengths attend to physical hygiene of female mentally ill or when a female
not been optimally utilized in the recovery of people with mental illness. caregiver is responsible for controlling a violent mentally ill relative’s
Psychiatric rehabilitation never becomes successful without the dangerous behavior), the stress can be exacerbated.
involvement of the family members considering the limited resources However, there is now growing recognition among service
available in the country. According to Wig (2000), “Family support, providers and researchers that family care giving will become more
which is so easily available in developing countries, is the anchor of significant in the future because of demographic, economic, and social
treatment and rehabilitation of the mentally ill in the outpatient changes in the late twentieth century that are anticipated to continue
management.” Unlike developed countries, mental health services in into the next century.
India not only encourage family involvement, but also often make it a
A responsible caregiver is one who:
pre-requisite of care (Stanhope, 2002). During the process of
psychiatric rehabilitation, it is the whole family which is being helped • Lives close to PWMI
through a variety of interventions directed towards patient and family • Has good emotional relationship with the PWMI
members. The family involvement includes parents, spouses, siblings,
children and close relatives. In this chapter, the interventions focused • Has positive attitude towards the PWMI
towards involvement of family in rehabilitation process are discussed. • Has time for the PWMI
114 PSYCHIATRIC REHABILITATION PSYCHIATRIC REHABILITATION 115

• Has patience. their attitudes and also formulate and implement coping skills and
preferred instruction with affected member. This type of family
• Is positive in approach to the condition of mental illness.
intervention involves a combination of education and improved
• Is motivated to care and also has capacity to motivate communication, problem solving, and processing of emotions for both
the PWMI. family members and affected individuals.
• Has the ability to create favorable atmosphere for the The education is usually imparted through individual or group
PWMI to be rehabilitated at home. sessions. The sessions focus on the diagnosis, symptoms, course,
The basic aspects or elements of care a person with mental illness causes, medication, prognosis and outcome. This will help the family
requires are; in understanding the problems of person with mental illness better
• Motivating and monitoring a PWMI for maintaining and plan for his/her rehabilitation. The education in turn will help in
personal hygiene reducing the expressed emotions of the family towards the person
with mental illness. It is mandatory to provide basic psycho education
• Provision of adequate amount of nutritious food to all the families of persons with mental illness be it at the in-patient,
• Medication/supervision of the intake of medicine by out-patient or at the community level. Preferably, the education should
PWMI be given by trained health professionals who may be Psychiatric Social
Workers, Psychiatrists, Psychologists, Nursing staffs, Rehabilitation
• Motivating the PWMI for taking small responsibilities
counselors etc. The information should not be given in a single booster
• Engaging the PWMI in income generation/productive session as too much of overloading of information may make the
activities family members unable to grasp the content. It is preferable to divide
• Create awareness among the community so that the the sessions based on the individual requirement of the family. The
PWMI is accepted and integrated in all community date, time and venue should be fixed prior to the session, so that the
activities families can reschedule their personal appointments and get engaged
without any disruptions. The information can be provided to parents,
• Encouraging the PWMI for socialization
siblings, spouses, in individual, joint session and conjoint sessions. The
Family Psychoeducation affected person can be given a separate session, otherwise the family
According to Goldman (1988), psychoeducation is “Education or members may not be able to verbalize their feelings. Due to
training of a person with a psychiatric disorder in subject areas that apprehension they may either remain silent of not divulge the illness
serve the goals of treatment and rehabilitation”. details at all.

The knowledge about the illness among the family members is The mode of presentation can be either didactic lecture, interactive
usually poor or inadequate which stress the need for psychoeducation with video footage of case vignettes, pamphlets, brochures and other
in a systematic way. Psychoeducation is a process by which we reading material. One should not expect major changes immediately
impart knowledge of illness to family with continual assistance, modify after the session as it takes time for information to percolate and
116 PSYCHIATRIC REHABILITATION PSYCHIATRIC REHABILITATION 117

attitudes and beliefs which are deep rooted, long standing can change they can start the same at home and sell the products and thereby
only over a period of time. In between the session there should be a earn income. Since the family member is also trained, any minor
pause for the family members to reflect on the information and difficulties due to illness or relapse may not affect their income largely
clarification and all the queries need not be answered then and there as the family member can keep the production going.
itself. The family can be assured of being provided all the answers in The family members may be provided an intensive sensitization
the subsequent session also. Care should be taken not to use technical programme to make them aware about the various schemes by the
jargon, simplify the information to suite the knowledge level of the scheduled banks to avail small loans for starting an enterprise. Many
family members. Be patient and listen to the distress of the family a times NGOs do provide micro finance for these ventures. Even the
members, encourage them to ask questions, they may ask the same caregivers may be encouraged to form an association and start co-
information repeatedly, but do not reprimand. Be sensitive to the verbal operatives for selling the products. The families may have manpower
and nonverbal expression of the family members. It is always good and resources coupled with motivation to start a unit but they suffer
to provide information in their own local language. from space constraints, the infrastructure may be deficient to
accommodate a business unit. In such cases families may be
Involvement of family in economic independence of patient
encouraged to discuss this issue in the support group meetings so
One of the major felt needs of the patient and family is economic that families with enough space which is unutilized may volunteer to
independence of the patient. In the process of helping the patient, the provide space and thus get involved in the collective venture.
family may also lose the income of the caregiver too which creates a
The Entrepreneur functions like manufacturing, selling, marketing,
lot of economic insecurity. Families are not clear as to how they can
fund rising, accounts, publicity, liaison, coordination may be delegated
help their family member in getting them a job or making them
among the family members of the caregivers, so that no one family is
economically independent. The psychiatric rehabilitation interventions over burdened with the task. Families as far as possible should be
can focus on educating the family about the skills and capacity of the encouraged to take up income generating livelihood programmes for
patient and the vocations that can be taken up by the person. The their sustenance.
families can be helped in identifying the resources available in and
Suggestions For Family Members (Do’s and Don’ts)
around the locality to place the client. This will help the families in
utilizing the resources and negotiate for the placement of their family • Quality of time is important than quantity of time.
member on their own. • Family should know what is happening between members
Another option of involving the family members is to encourage to improve the emotional bonding. This allows for better
them to undergo a vocational training along with their ward and initiate communication among family members.
some self employment activities. For example, candle making, food • Healthy recreation is essential for all family members.
processing, photocopy, crafts, greeting cards, etc. Most of the times,
• Families should be flexible to each other’s needs.
patients may not be fully independent in doing these activities. They
need constant supervision and support in the preparation of products. • Families should have good interaction with the
Once the patient- caregiver dyad is trained in particular vocation, neighbourhood.
118 PSYCHIATRIC REHABILITATION PSYCHIATRIC REHABILITATION 119

• They should not hesitate to seek help and support References:

whenever they need. Support can be physical, emotional, • Janardhana, N., Shravya R, Naidu DM, Sarawathi C,
material, information seeking, etc, from professionals and Valli Seshan (2011). Giving care to men and women
supporting people and organizations. with mental illness . Indian journal of gender studies Vol
• On the whole, families should be involved in planning 18 (3);381-405
short-term and long-term goals for the patient. The • Kumar, G. S. U., Thomas, B., Henry, J., Parthasarathy,
outcome of the interventions depends on family’s R., & Sekar, K. (2008). The Healthy Family: A
participation in treatment, medication as well as recovery. Workbook for Family Counselors. Indian Society of
_______________ Professional Social Work.
* Associate Professor,
* * PhD Scholar • Stanhope, V. (2002). Culture, Control and Family
Department of Psychiatric Social Work
National Institute of Mental Health & Neurosciences, Bangalore. Involvement: A Comparison of Psychosocial Rehabilitation
in India and the United States. Psychiatric Rehabilitation
Journal, 25 (3): 273-280
• Varghese, M., Shah, A., & Kumar, G. S. U. (2002). Family
Intervention and Support in Schizophrenia. A manual on
Family Intervention for the Mental Health
Professional. WHO/NIMHANS (version 2).
• Wig, N. (2000). World Health Organization and Mental
Health: A view from developing countries. Bulletin of
WHO, 78 (4): 502-506.
120 PSYCHIATRIC REHABILITATION PSYCHIATRIC REHABILITATION 121

COGNITIVE FUNCTION ASSESSMENT IN suffer from cognitive deficits. The condition becomes worse if they
REHABILITATION SETTING have co-morbid diagnosis. Suppose an individual has Mild Mental
Retardation and at some point of time in his/her life suffers from
*
Poornima Bhola, Schizophrenia for a longer period of time, the person may have more
**
Aarti Taksal, cognitive deficits than an individual with Schizophrenia. It should be
***
Poornima Bhola kept in mind that the severity of cognitive dysfunction depends on
Introduction: several factors. These factors include long duration of illness, number
of episodes, level of functionality before the onset of illness, co-morbid
Mental illness not only causes emotional problems, but also affects
diagnosis, etc. In case of Mental Retardation it depends on the level
cognitive skills of the person afflicted with it. The severity of cognitive
of retardation and also co-morbidity.
dysfunction is less in some cases but more in Severe Mental Illness
(SMI) like Schizophrenia or Bipolar Disorder. Cognitive dysfunctions Need for assessing cognitive functions:
are persistent in the absence of psychotic symptoms. Clients with • To differentiate mental retardation from other mental
SMI have varied cognitive dysfunctions. They have difficulty to pay illness.
attention to more than one stimulus, lack planning, have difficulty to
remember office appointments, etc. As a result their functionality is • To assess the current level of intellectual functioning of
hampered. the client.

Clients with Mental Retardation experience difficulty in carrying Intellectual skills are not dynamic processes as they are static
out their activities of daily living (bathing, brushing, dressing, etc.) construct. But at times the result may be coloured by present
and instrumental activities (travelling, money management, etc.) owing psychopathology or by other factors where reassessment is
to their below average intellectual functioning. It is directly proportional needed once the client is stable. Hence the term current is
to their severity of retardation. This means if a person has Severe always emphasized while assessing cognitive functions.
Mental Retardation, he/she will be more dependent on others than a
• To measure intellectual strength and vulnerabilities of the
person with Mild Mental Retardation. They also suffer from poor
client.
attention and memory span, or in other words they have poor cognitive
skills. Cognitive function assessment provides a comparative data
about individuals’ strengths and weaknesses. Strengths can
The term cognitive function includes various processes through
be utilized to improve individual’s weaknesses in his/her
which individual perceives, registers, stores and retrieves information
rehabilitation plan.
in his/her daily activities. These processes include intelligence, learning,
memory, attention and concentration, perception, etc. Cognitive • To assess severity of deficits as chronic mental illness leads
function assessment determines an individual’s ability to process these to cognitive deficits.
cognitive processes.
Chronic mental illness may lead to cognitive deficits. Some
Individuals with Severe Mental Illness and Mental Retardation cognitive function assessment provides information about how
122 PSYCHIATRIC REHABILITATION PSYCHIATRIC REHABILITATION 123

much deficits had happened due to long duration of mental • Mental Status Examination
illness. It also tells us the pre-morbid level of intellectual
• Psychological assessment
functioning of the individual before the onset of the illness.
Mental Status Examination and Cognitive functioning:
• To make rehabilitation plan with regard to activities of
daily living, instrumental activities, occupation, etc. Mental Status Examination (MSE), one of the components of
Cognitive deficits interfere in daily functioning of the individual psychiatric interviewing, is the online monitoring of the client’s mental
with chronic mental illness/mental retardation. To help them to status. The interviewer screens the mental status to detect signs and
lead a meaningful life rehabilitation plan should be made symptoms of mental disorder (Sadock & Sadock, 2005). Cognitive
according to their capabilities. function is one of the components of MSE. Other components include
• To issue disability benefits on the basis of Intelligence appearance, psychomotor functions, speech, thought, insight, etc. MSE
Quotient (IQ). is a snapshot of the client’s cognitive functions. Cognitive functions
include:
Individuals with mental retardation can avail benefits (like
concession in transportation, pension, etc.) provided by the state/ A. Attention & Concentration: (Strub & Black, 2003)
central government on the basis of level of retardation. a) Digit forward and digit backward
When do we do cognitive function assessment?
9 Client’s basic level of attention can be readily assessed
• Assessment is usually started when the client is free from any by this test.
active symptom.
9 Adequate performance suggests client’s ability to attend
• Rapport building is necessary before administration of test as to verbal stimulus and to sustain attention for a required
it optimizes the level of performance of the client.
period of time.
• Acquiring knowledge about client’s history and background
b) Serial Sevens Subtraction Test
information is necessary.
9 The client is required to count backward from 100 by 7s:
• Referral from any mental health professional.
(100, 93, 86….).
Various sources of gathering information to assess cognitive
functions: 9 Excellent performance indicates adequate attention and
• History one of the reasons of failure could be inattention.

• Informant’s information c) Counting 20-0

• Behavioural observations 9 The client is required to count backward, from 20 to 0.

• School records/performance at workplace/rehabilitation centre 9 Client is required to give correct answer within 15 seconds
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d) Naming days of the week/month in reverse order Assessment of cognitive functions through standardized
9 This test is usually administered on illiterate client, where psychological test:
the above mentioned tests can’t be administered. Psychological tests are standardized scientific tools meant to
9 Performance without any error indicates adequate assess various psychological constructs. Properties of psychological
attention. tests are:
B. Memory: Reliability: How likely it is to produce the same results if used
again in the same circumstances. E.g., if an individual’s IQ is measured
Clinically, memory is subdivided into three types, based on the
time span between stimulus presentation and memory retrieval. These more than once, it should give us the same range of IQ.
basic types of memory are immediate, recent, and remote (Strub & Validity: It refers to the ability of the test to measure what it
Black, 2003). purports to measure. E.g., IQ test should measure domains of it not
a) Immediate memory: Refers to recall of memory trace after any other constructs.
an interval of few seconds. Immediate memory is usually Norms: The test must have a range of values within which
measured by digit forward and backward. members of a given population are expected to perform or function.
b) Recent memory: Refers to the ability to learn new material E.g., tests which are used at India should have a norm for Indian
and to retrieve that material after an interval of minutes, hours, population in terms of range of values with regard to various socio-
or days. Orientations to time, place, and person, current date, demographic details.
recent news, etc. are example of recent memory.
Please note that below mentioned tests have Indian norms
c) Remote memory: Refers to the recall of facts or events that with specific instruction and procedure to follow and require
occurred years previously. Tests of remote memory are the trained mental health professional to administer the test.
recall of client’s personal information and historic events.
A. Attention & Concentration
C. Higher cognitive functions:
Attention is the client’s ability to attend to a specific stimulus
Attention and memory are the building blocks for the
without being distracted by extraneous internal or environmental
development of higher intellectual abilities. Manipulation of well-
stimuli (Umilta, 1988). Concentration (sustained attention) is the ability
learned material, abstract thinking, problem-solving, judgment,
to maintain attention to a specific stimulus over an extended period
arithmetic computations, and so forth, represent the highest level of
(Strub& Black). Attention and concentration of client must be
human intellectual functioning (Strub & Black, 2003). In general, the
higher cognitive functions include the fund of acquired information or established before evaluating more complex functions, such as
the store of knowledge, the manipulation of old knowledge (e.g. memory, intelligence, etc. The inattentive and distractible client cannot
calculation or problem solving), and abstract thinking (e.g. efficiently assimilate the information being presented during testing
interpretation of proverbs or the completion o conceptual series) (Strub (Strub & Black, 2003). Commonly used test to evaluate attention
& Black, 2003). and concentration at our rehabilitation setting are:
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a. Digit Symbol Substitution Test (NIMHANS • It is an individually administered battery of learning,

Neuropsychology Battery, 2004) memory, and working memory measures (capacity to
• Age range is 16-65 and is used on literate individuals. remember and manipulate both visually and orally
presented information in short-term memory storage)
• Apart from measuring sustained attention, it also
measures visuo-motor coordination, motor persistence and • The test is comprised of 11 subtests, with 6 primary
response speed. subtests and 5 optional subtests.
• The test consists of a sheet in which numbers 1-9 are • 6 primary subtests are Logical Memory, Faces, Verbal
randomly arranged in 4 rows of 25 squares each. Paired Associates, Family Pictures, Letter-Number
• The subject substitutes each number with a symbol using Sequencing and Spatial Span.
a number symbol key given on the top of the page. • 5 optional subtests are Information and Orientation, Word
b. Digit Vigilance Test (NIMHANS Neuropsychology Lists, Visual Reproduction, Mental Control, and Digit Span.
Battery, 2004) b. PGI Memory Scale ( Pershad & Wig, 1994)
• Age range is 16-65 and is used on literate individuals. • The age range is 20-45 years.
• This test measures the ability to sustain and focus • It is a short, simple, objective and valid test of memory in
attention. Indian scenario.
• The test consists of numbers 1 to 9 randomly ordered • The test contains 10 subtests.
and placed in rows on a page.
• 10 subtests are Remote Memory, Recent Memory,
• There are 30 digits per row and 50 rows on the sheet.
Mental Balance, Attention-Concentration, Delayed Recall,
The digits are closely packed on the sheet.
Immediate Recall, Retention for similar pairs, Retention
• The subject has to focus on the target digits i.e. 6 and 9 for dissimilar pairs, Visual Retention, and Recognition.
amongst other distracter digits.
• This test is not dependent on intelligence and is equally
B. Memory valid for both sexes and applicable and acceptable to
Memory is the ability to retain and reproduce impressions once illiterate and unsophisticated subjects.
perceived intentionally. The interrelated processes involved in memory C. Intelligence:
are registration, storage and retrieval of information. The most
commonly used memory test is According to Wechsler (1944), intelligence is “the aggregate of
the global capacity to act purposefully, to think rationally, to deal
a. Wechsler Memory Scale-III-IND (WMS-III-IND)
effectively with the environment.” Performance on standardized
(Gurappa & Rao, 2009)
intelligence test and evaluation of socio-adaptive functioning are two
• The test is intended for use with older adolescents and important criteria to assess an individual’s intelligence. Some important
adults, age 16-50 years. terms to be remembered:
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Intelligence Quotient (IQ): The IQ is defined as the ratio of • Available in English, Kannada, Marathi, Gujarati, and
mental age to the chronological age or real age, multiplied by 100. Hindi.
IQ=Mental Age/Chronological Age×100 • Measures Basal Age, Terminal Age, and Intelligence
Quotient (IQ).
Mental Age: Mental age is a score which is obtained by
comparing a client’s obtained score with the average score at his/her • Provides profile analysis. The domains are language,
age level (Singh, 1998). meaningful memory, non-meaningful memory, conceptual,
non-verbal reasoning, verbal, numerical, visuo-motor,
Individual Intelligence Test: An Individual Intelligence Test
social intelligence.
is one which can be administered to one person at a time.
Wechsler Adult Performance Intelligence Scale (Prabha
Group Intelligence Test: A Group Intelligence Test is one which
Ramalingaswamy)
can be administered to more than one person at a time, that is, it can
be administered to a group (Singh, 1998). • Indian adaptation of WAIS performance scale
Verbal Test: A Verbal Test is one in which the instructions and • Performance and individual test of intelligence and
items are reproduced usually through the written language before measures Performance Quotient (PQ).
the client (Singh, 1998) • Minimum 5th grade educational qualification is required.
Performance Test: A Performance Test is one where language • Age range is 15-45years.
is used to impart instruction and items are manipulative in nature
(Singh, 1998). • Subtests are Picture Completion, Digit Symbol, Block
Design, Picture Arrangement, and Object Assembly.
Socio-Adaptive Functioning: Adaptive behavior is the
functional ability of the individual to exercise personal independence • 1974 by Manasayan, Rakesh Fine Art Printer, Delhi
and social responsibility. Social adaptability is the effectiveness of Bhatia Battery of Performance for Intelligence ([Link])
the individual in coping with the natural and social demands of his/her
• Performance and individual test of intelligence and
environment.
provides Performance Quotient (PQ) and Intelligence
Social Age: Quotient (IQ).
Social Quotient (SQ): SQ is the ratio of Social Age to the • Subtests are Block Design, Pass Along Test, Pattern
Chronological Age multiplied by 100 which is also as a Proximate Drawing Test, Immediate Memory, and Picture
IQ. Construction Test.
Binet-Kamat Test of Intelligence • This test is not administered on individual with mental
retardation.
• No educational qualification is required.
Seguin Form Board Test
• Age range is 3-22 years, but can also be used on client
beyond 22 years of age. • Most commonly used performance test.
130 PSYCHIATRIC REHABILITATION PSYCHIATRIC REHABILITATION 131

• Measures psychomotor and visuo-perceptual abilities for c. American Association on Mental Retardation (AAMR)
children between 4 and 20 years. Adaptive Behaviour
• It is a quick measure of general intelligence in children • It gives a quantitative description of the coping behavior
between 3 and 11 years and for adults with mental of a person with mental retardation.
retardation. • The scale has two parts.
Other tools include Wechsler Adult Intelligence Scale (WAIS), • The first part covers the levels of development in ten
Ravens Progressive Matrices, etc. areas of functioning such as language, socialization,
D. Socio-Adaptive Functioning independence, etc.
a. Vineland Social Maturity Scale (VSMS) • The second part is concerned with maladaptive behavior
under f14 different categories, for eg., violence, antisocial
• Measures socio-adaptive functioning over 8 domains.
behavior, etc.
• Information is gathered by means of semi-structured
How to integrate assessment findings:
interviews with the client or guardian/caretakers.
1. The report must always contain essential data such as
• Age range is 0-15 years, but can be used beyond 15
age, sex, years of schooling, the names of the test
years of age.
administered, date of administration, etc.
• Provides Social Age and Social Quotient (SQ).
2. It must also contain brief history and behavioural
• 8 domains are self help general, self help eating, self help observation made during test administration.
dressing, socialization, locomotion, communication, self
3. Interpretation of results should be made in simple words
direction, and occupation.
and it should be communicated clearly.
b. Vineland Adaptive Behaviour Scale-II (VABS II)
4. Any discrepancy between mental age and social age need
• Available in Parent/Caregiver and Teacher Rating Form. to be mentioned and possible reason behind the
discrepancy needs to be clarified.
• Age range from birth-90 years. Age range for Teacher
Rating Form is 3-21years. 5. Report should always contain recommendations. It should
be realistic and practical.
• Domains are Communication, Daily living skills,
Socialization, and Motor skills. Each domain has various 6. Feedback of test results should be given to client, family
sub-domains. members and referral source.
_______________
• Provides Maladaptive Behaviour Index (externalizing, * Associate Professor
Department of Clinical Psychology
internalizing, others). National Institute of Mental Health & Neurosciences, Bangalore.
132 PSYCHIATRIC REHABILITATION PSYCHIATRIC REHABILITATION 133

References SOCIAL SKILLS: ASSESSMENT AND

• Wechsler, D. (1997). The Wechsler Memory Scale-Third INTERVENTIONS IN RECOVERY
Edition. San Antonio, TX: The Psychological Corporation. ORIENTED SERVICES
*
• Umilta, C: Orienting of Attention. In Boller, F and Aarti Taksal,
**
Grafman, J (eds): Handbook of Neuropsychology, Vol 1. Fatema Khanam,
***
Elsevier Science Publishers, Amsterdam, 1988, pp 115- Poornima Bhola
193
Introduction:
• Richard L. Strub& F. William Black (2003).The Mental
Human beings, by nature, are social creatures, and thus, the quality
Status Examination in Neurology, 4th [Link]
of the social life will influence one’s mental health and overall
Brothers, Medical Publishers (P) Ltd, New Delhi
adjustment. Competence in negotiating with one’s social world is
• [Link]’s Performance Test of Intelligence under important in order to have a satisfactory quality of life.
Indian Conditions (Oxford University Press)
Social impairment is seen in many psychiatric disorders, but is a
• Pushpalatha Gurappa & [Link], 2009, published
hallmark of schizophrenia. Social skill deficits are also seen in bipolar
by Pearson Clinical & Talent Assessment
disorder, developmental disorders, disruptive behaviour disorders,
depression, anxiety, and personality disorder. Though pharmacological
management results in symptomatic recovery in patients with
schizophrenia, social dysfunction continues in a majority of patients.
The schizophrenia PORT treatment recommendations (Lehman et
al., 2003) included provision of social skills training as an adjunctive
treatment method for patients in order to improve their social
functioning.
What are Social Skills?
Knapczyk and Rodes (2001) define social competence as the
‘ability to achieve legitimate, personally relevant goals’ through
interacting with others in all situations: work, school, home and
neighbourhood, recreation, shopping and consumer services, medical
and mental care, and social and legal agencies. The skills required
for being socially competent are called social skills. These “skills”
are behaviours, which when put together in an appropriate sequence
134 PSYCHIATRIC REHABILITATION PSYCHIATRIC REHABILITATION 135

and appropriate social context, enable a person to interact competently

with others. Such success in social interaction is rewarding to the
person, as this facilitates not only fulfilment of his/her affiliative needs
but also boosts his/her self-esteem, self-efficacy, mood and feeling
of empowerment (Kopelowicz et al., 2006).
Bellack and Hersen describe social skills as the “ability to express
both positive and negative feelings in the interpersonal context without
suffering consequent loss of reinforcement. Such skill is demonstrated
in a large variety of interpersonal contexts and involves the coordinated
delivery of appropriate verbal and nonverbal responses. In addition,
the socially skilled individual is attuned to the realities of the situation
and is aware when he is likely to be reinforced for his efforts” (1979,
p. 512). They consist of the ability to give and obtain information, On the basis of the above mentioned aspects, the process of
express and exchange opinions and feelings. social skills can be divided into Receptive Skills, Processing Skills
and Sending Skills.
The use of the term skills suggests that these behaviours are
learnt; these are not innate abilities that a person is born with.
Instrumental social skills are skills used for social interactions
which are aimed at achieving tangible goals. Some examples are:
shopping, travelling by a bus, money management, using the health
system, asking for directions. Social-emotional skills are ends in
themselves and are used to fulfil affiliative needs of a person. Some
examples of these skills are: starting a conversation with a new
neighbour, greeting a colleague, discussing with a friend, sharing
emotional experiences with others, enquiring about the spouse’s health.
Social-emotional skills are generally required to form and maintain
relationships with others.
What is assessed in social skills?
In any social interaction, there are four aspects of social skills
which come into play.
136 PSYCHIATRIC REHABILITATION PSYCHIATRIC REHABILITATION 137

Methods of assessing social skills Always Often Rarely Never

A person’s behaviour has to be understood in the context of his (4) (3) (2) (1)
or her cultural background and the given social context. What may
Patient rating:
be appropriate to say or do in one situation, may not be so in another
context. The clinician should be culturally sensitive while make Are you able to initiate conversation with friends or a group?
evaluations about the patient’s social skills. Several methods are Are you able to understand feelings of others by looking at
available for assessing social skills. Assessment is comprehensive them?
when information obtained from at least two of these methods is
Are you able to negotiate with others if you disagree with
combined.
them in an issue?
1. Interview method
Caregiver rating:
2. Rating scales
Does s/he maintain relationships?
3. Role plays
Is s/he able to travel alone to a destination or purchase items
4. Naturalistic observations from a shop?
1. Interview method Is s/he able to express his emotions appropriately with others?
In this method, caregivers are interviewed regarding the social Clinician rating:
interactions of the patients. Caregivers can be asked about the nature,
Gaze (eye contact)
frequency and duration of social interactions of their patients. Specific
information about the verbal, non-verbal aspects of communication Verbal (The content of speech)
can be elicited. Other social skills deficits observed by the caregivers Appropriateness of affect
can be noted.
Such a rating may give an objective measure of how much deficit
An interview along similar lines can be carried out with the a patient has in various social skills. It also provides scope for a pre-
patients themselves. This would be helpful in understanding how they post comparison following social skills training.
perceive social interactions, their felt needs and what exactly they
find difficult during a social interaction. This can also help build a 3. Role plays
rationale for social skills training with the patients. The role play is a very useful method for assessing social skills of
2. Rating scales patients. Through the use of role plays, real life situations can be
simulated and the patient’s behaviour and skills can be observed
Caregivers, patients and clinicians as well, can rate various aspects directly. This method overcomes the disadvantages of the use of
of social skills on a likert type scale. On a Likert scale items are interviews or rating scales where there may be under or over reporting
rated on any of the four points: of social skills deficits. Role plays are useful as they give a glimpse
138 PSYCHIATRIC REHABILITATION PSYCHIATRIC REHABILITATION 139

of exactly a patient may respond in commonly occurring social rated on different dimensions of social skills, example eye
situations, requires the patient to think on his/her feet. Based on the contact, appropriateness of verbal content, ability to maintain
performance of the patient in the role play, the clinician can make an role in the scene, facial expression, body posture, etc.
assessment of the different aspects of his/her social skills. The same 4. Naturalistic observations
role play situations can be used to examine the social skills of patients
This method involves observing the patients in their natural
after the social skills training is completed.
environment, such as home, or workplace, or in the rehabilitation
9 In role play participants are presented with a social situation centre or day care centre. Since this does not involve any manipulation
involving a confederate who plays the scripted role of another of social situation (such as in a role play test) inferences about social
person. skills and deficits can be made in an unbiased manner. Anxiety, which
9 The social situations may involve initiating a conversation, may arise in a role play situation because the patient may feel
making a complaint, solving a problem, etc. “watched” or very self-conscious, is absent when patients are
observed in their natural environment.
9 Role play enactments are usually preceded by a 90sec practice
role play to orient the participant to the task. Description of some of the tools for assessing social skills

9 The participant is provided with the description of the enacted Maryland Assessment of Social Competence (MASC;
Bellack & Thomas-Lohrman, 2003):
scenario first and she is informed who s/he will be enacting in
the interaction to ensure that participant understand his/her The MASC is a role play test which uses a series of four 3-
tasks. minute role played conversations. The time taken for administration
is approximately 20 minutes for each patient. Four situations of role
9 Role play starts by the confederate who delivers a prompt line
play that are assessed are: a) conversing with casual acquaintance,
to begin the interaction.
b) discussion with mental health care worker, c) negotiating and
9 The confederate takes different perspectives on the problem compromising, d) standing up for one’s rights. Role plays are either
at approximately 1minute and 2minute after the interaction videotaped or audiotaped after obtaining consent from the patient
begins. and are rated on verbal skill, non-verbal skill, and overall effectiveness,
on a scale of 1 (very poor) to 5 (very good). The range of possible
9 For example, the participant needs to get a landlord to fix a
scores on this test was 12-60. Normal, healthy controls are known to
leak. For the first minute, the confederate/landlord makes
perform towards the higher end of the scores, i.e., at near-ceiling
noncommittal responses: “I have been trying to get there. It
levels, on this test (Dickinson, Bellack, & Gold, 2007).
isn’t too bad is it?”, during the second minute s/he suggests
that the participant do something such as putting a bucket under Test of Grocery Shopping Skills (TOGSS; Hamera & Brown,
the leak, and for the third minute s/he speaks evasively: “You 2000):
are on my list” or “I’ll get to it as soon as I can”. The TOGSS is a real life task which requires patients to go to a
9 The interaction is audiotaped or videotaped and subsequently grocery store, buy the items on the grocery list given to them. However,
140 PSYCHIATRIC REHABILITATION PSYCHIATRIC REHABILITATION 141

they need to buy the brands which are of the lowest cost, and they inadequate social skills are found in the areas of ability to initiate a
have to shop efficiently. The patients are rated on whether they bought conversation, an ability to engage in activities with others. Adequate
the correct item, was it the most inexpensive of all available brands social skills are found in the area of grooming and appearance.
and was it the correct size/weight. Shopping is a complex social task Conclusion
as it involves planning, negotiating with shopkeepers. It is also a part
of everyone’s daily routine. Thus this test assesses one of the most Social skills’ training is an important psychosocial intervention
for facilitating functional recovery in patients with schizophrenia. For
important instrumental social skills.
the intervention to be successful, it is important to identify baseline
Tools developed at NIMHANS: deficits in social skills. Assessment methods such as interview, role
Social Skills Questionnaire: play tests, naturalistic observations, and rating scales can provide a
This questionnaire requires the caregiver to rate whether a given comprehensive picture of the social skills and deficits of patients.
behaviour or skill is demonstrated by the patient ‘Always/Usually/ _______________
* PhD,
Sometimes/ Rarely/Never’. Some examples of the item are: Does * * Clinical Psychologist,
he / she greet familiar peers and adults?, Does he / she greet new ***Associate Professor, Department of Clinical Psychology
National Institute of Mental Health & Neurosciences, Bangalore.
non-familiar peers and adults?, Does he / she bargain in market for
costly things?, Does he / she is able to maintain a conversation on a
non-preferred topic?, Does he / she interrupt appropriately saying
“excuse me” or apologize for interrupting?, Does he / she offer help
to others if they are hurt or sick?, Does he / she help others in their
work?, Does he / she talk repeatedly on a topic even when the other
person is getting bored?
Rating Scale for Social Skills:
This questionnaire was developed by Psychiatric Rehabilitation
Services team of NIMHANS. This is 3 points rating scale consisting
of 20 items assessing components of social skills across three broad
domains- Non-Verbal Behaviour and Communication, Verbal
Communication and Social Behaviour. Scores of 2, 1 and 0 are
given for adequate, average and inadequate social skills for each
item respectively. The questionnaire was piloted on 59 in-patients
with varied psychiatric diagnoses at their first contact with a mental
health trainee at PRS from May-July, 2012. Statistical analysis reveals
that the tool has high internal consistency. Results further reveal that
142 PSYCHIATRIC REHABILITATION PSYCHIATRIC REHABILITATION 143

References: VOCATIONAL REHABILITATION OF

• Knapczyk D, Rodes P. Teaching Social Competence. PERSONS WITH PSYCHIATRIC
Champaign, Illinois: Research Press; 2001. DISABILITY
*
• Bellack AS, Mueser KT, Gingerich S, Agresta J. Social Faseela Jaleel,
**
Skills Training for Schizophrenia. New York, NY: Guilford B. P. Nirmala
Press;2004. Introduction:
• S. Bellack and M. Hersen (Eds). (1979). Research and Vocational rehabilitation is one of the main areas of psycho social
practice in social skills training New York: Plenum. rehabilitation. Therefore, employment is considered as a major
• Hamera, E., & Brown, C. E. (2000). Developing a outcome measure in the recovery of persons with psychiatric
context-based performance measure for persons with disability. According to Liberman (2012), the concept of recovery in
schizophrenia: The Test of Grocery Shopping Skills. functional criteria is operationally explained as (a) symptoms low
American Journal of Occupational Therapy, 54, 20– enough in severity and frequency so as not to impede everyday
25. functioning; (b) work in a competitive, market job or attending a normal
school at least half time; (c) reasonably cordial family relationships,
• Kim T. Mueser,*, Sarah I. Pratt, Stephen J. Bartels, Brent
recognizing that occasional family discord is normal; (d) social
Forester, Rosemarie Wolfe,and Corinne Cather.
relationships with at least one friend with whom one engages in social
Neurocognition and social skill in older persons with
and recreational activities in normative community environments at
schizophrenia and major mood disorders: An analysis of
least once every two weeks; (e) independent living as defined by
gender and diagnosis effects. Journal of Neurolinguistics.
money management, illness management, self -care, personal hygiene
2010 May; 23(3): 297–317. NIH Public Access
within normal standards.
• Alan S. Bellack, Clayton H. Brown, Shannon Thomas-
In spite of the growing evidence regarding the effectiveness of
Lohrman. Psychometric Characteristics of Role-Play
employment in functioning and recovery, individuals with more severe
Assessments of Social Skill in Schizophrenia.
psychiatric disabilities have the lowest rates of labor force participation,
• University of Maryland School of Medicine and VA and the lowest employment among all disability groups (Loveland et
Capitol Health Care Network MIRECC. Behavior al. 2007). Even after getting into a mainstream job, they may have to
Therapy 37 (2006) 339-352 face many challenges due to the difficulties caused by illness, disability,
demands of the job market, stigma, etc. At this stage, vocational
rehabilitation emerges as a major therapeutic intervention in the
process of psychiatric rehabilitation. Training in vocations has many
targets including symptom reduction, reduction of Expressed
Emotions, social skill development, improvement in cognitive functions,
144 PSYCHIATRIC REHABILITATION PSYCHIATRIC REHABILITATION 145

etc., but the most important goal is to have a financially viable approximately 300 clubhouses in various countries around the world,
occupation. Vocational rehabilitation is based on the assumption that many of which are accredited by the International Center for
work not only improves activity, social contacts etc., but may also Clubhouse Development (ICCD). Clubhouses are communities where
promote gains in related areas such as self-esteem and quality of members can gain confidence and support, and can receive assistance
life, as work and employment are a step away from dependency and to lead vocationally productive and satisfying lives. The clubhouse is
a step to integration into society (Rossler, 2006). Vocational organized around a work-ordered day program that provides
rehabilitation significantly improves social functioning, cognitive opportunities for members to work within a rehabilitative environment.
functioning and psychopathology (Kumar, 2008). It provides A Clubhouse is first and foremost a local community center that offers
opportunities for social interaction, a means of structuring and people who have mental illness hope and opportunities to achieve
occupying time, enjoyable activity and involvement, and a sense of their full potential. Much more than simply a program or a social
personal achievement (Rinaldi and Perkins 2004). Hence, the ultimate service, a Clubhouse is most importantly a community of people who
goal of all rehabilitation interventions is to help the client in achieving are working together to achieve a common goal. During the course
financial independence and thereby re-integrate the client to the of their participation in a Clubhouse, members gain access to
community. opportunities to rejoin the worlds of friendships, family, employment
and education, and to the services and support they may individually
Development of Vocational Rehabilitation need for their recovery. A Clubhouse provides a restorative
Competitive employment has not been a major focus of the mental environment for people whose lives have been severely disrupted
health system. There has been a tendency to adopt minimal because of their mental illness, and who need the support of others
expectations and lower standards of achievement for people with a who are in recovery and who believe that mental illness is treatable.
mental disorder. Socio-structural barriers and disincentives have also Clubhouses are divided into various work units designed to manage
made it difficult for people with a mental disorder to get in and stay in everyday tasks associated with the operation of the clubhouse. Typical
the competitive workforce. Vocational rehabilitation efforts have been work units may include Clerical, Food Services, Facilities/
a great deal of support to those finding it difficult to get into the Environmental, Reach Out (contacting and supporting members who
regular job market due to psychiatric disability. have not attended the Clubhouse in a while), Membership, Education,
The concept of vocational rehabilitation has progressed through Advocacy, Social Recreation, and Employment. The work of each
the years and has taken various shapes according to the needs of unit is further divided into specific, manageable tasks. When a member
people suffering from mental disorders and mental retardation. The joins the clubhouse, he or she selects a “home unit”, according to his
various vocational models that were experimented worldwide and or her interests and abilities. The member can then sign up to perform
found successful in the rehabilitation of persons with psychiatric the unit tasks, giving him or her an opportunity to work side-by-side
with the clubhouse staff in a unique partnership and to contribute in
disability are as follows:
meaningful ways to the overall operation of the clubhouse. All member
1. Club House contribution inside the clubhouse is done so on a voluntary basis;
The clubhouse model grew from Fountain House, a consumer payment of a member to work in the clubhouse is considered
self-help organization first established in 1948. There are now unethical, regardless of work performed or hours put in.
146 PSYCHIATRIC REHABILITATION PSYCHIATRIC REHABILITATION 147

2. Transitional employment is part of the TE development process, there are many opportunities
to access personal introductions and references.
Transitional employment (TE) is the primary vocational approach
used by clubhouse programs, and is designed to give members real Transitional Employment is never considered as a charity to the
work experience, confidence, skills, and the opportunity for properly disabled by the employer as it is a “pay for work done” relationship.
paid work. The staff member provides training on the job, and assists It offers important and valuable benefits to an employer, including
the member with any other issues that may arise. the following:
The main features of TE programs are: • No hiring process is needed.
• Positions involve 6-9 months of temporary work; • New employee training is done by the staff of clubhouse
members are paid award wages; at no cost to the employer.

• Members complete the work at the employer’s place of • Guaranteed perfect attendance where the clubhouse staff
business; covers member absences.

• All work is entry level and does not require qualifications. • Immediate response and resolution from the clubhouse
to any problems with the employee up to and including
• Limited work history or recent hospitalization will not
termination from the job.
affect a member’s opportunity to obtain a position.
• The job is done to the employer’s satisfaction.
• No resume or interview is required as the position is
‘owned’ by the clubhouse and the selection process is • There is no vacancy in the position between employees.
managed by the Clubhouse staff and members • Giving people with mental illness an opportunity is a
(Mental Health Council of Australia 2007) valuable community service and can provide positive
recognition for the employer.
Transitional Employment (TE) development is much like finding
one’s own job. As in a personal job search, the development of TE 3. Social firms
jobs is always facilitated by having personal contacts and references. Social firms originated in Italy in the 1960s and since spread
While the clubhouse will often have to make ‘cold calls’ to employers, throughout Europe and the United Kingdom and also in Australia.
if the targeted employer has been introduced to the clubhouse from a They are not-for-profit businesses that provide accessible employment
friend or business associate, the chance of getting the opportunity to for people with disability. Social firms usually have the following
present the program and secure a placement are greatly increased. features: 20-50% of positions are reserved for employees with
Therefore it is important that all the people involved with the clubhouse disabilities; all workers are paid the same award rate or productivity
and working for its success must be involved in TE development. based rates; all employees have the same employment opportunities,
Everyone-member, staff, board member, parent agency staff, and rights, and obligations. The social firm generates the majority of its
friends of the clubhouse may know someone who is a potential income through the commercial activity of the business, although most
employer for the clubhouse. When the whole clubhouse community are not self-sufficient (Mental Health Council of Australia 2007).
148 PSYCHIATRIC REHABILITATION PSYCHIATRIC REHABILITATION 149

The workplace design is also modified according to the requirement vocational assessment is carried out initially and then pre-vocational
of the employee in need of support. Social Firms Australia (SoFA) services are provided in generic work skills and personal development
originated in 2004 for creating accessible employment for people such as self-esteem, assertiveness, and stress management (Rinaldi
excluded from the workplace, particularly people with mental illness and Perkins 2007). This programme assumes that the participants
has emerged as a successful vocational rehabilitation model in require a period of preparation to enter into a competitive job that
Australia by creating a number of social firms. can be applied by anyone. The training includes sheltered workshops,
4. Sheltered work transitional employment, work crews, skills training, and other
preparatory activities through which participants can learn pre-
Sheltered workshops were originally designed for people with
vocational and work readiness skills. However, placements are often
intellectual disabilities. At that time it was commonly thought that
sheltered through being owned by the hospital or rehabilitation agency
competitive employment would be impossible. Sheltered work was
(Corrigan et al. 2007).
also used for family respite and for activity therapy for those who did
not have an employment goal. In the late 1980’s access was extended 6. Supported employment / Individual Placement and
to people with severe mental illness who presented with a low level Support
of functioning and who appeared unable to participate in competitive Supported Employment is a paid competitive employment in an
employment. integrated setting with ongoing support for individuals with the most
Workshop clients are often paid a small allowance or piece rate severe disabilities for whom competitive employment has not
well below that paid to employees in the wider community. Sheltered traditionally occurred, and who, because of the nature and severity
workshops provide an enclave type of work environment where every of their disability, need on-going support services in order to obtain,
worker has a disability. The work is usually repetitive and monotonous, perform, and retain their job. Supported Employment provides
and the jobs need not be complete on time as it is very flexible. assistance such as job coaching and job placement, assistance in
Workers seldom receive assistance to move on to a competitive job interacting with employers, on-site assistive technology training,
of their choice in the open labor market. The workshop is usually a specialized job training, and individually tailored supervision.
competitive business competing for contracts along with other Individual Placement and Support (IPS) is the best known and
businesses in the community. In the past, sheltered workshops sought best researched variant of supported employment developed by Drake
commercial contracts while operating in a protected and segregated & Becker with the primary goal of not changing the individual, but to
environment such as in a psychiatric institution (Corbiere and Lecomte find a natural match between the individual’s strengths and
2007). experiences and a job in the community. IPS is based on the eight
5. Pre-vocational services / Traditional Vocational key principles of Supported Employment (Bond, 2004) which includes
Rehabilitation (i) a single-minded focus on competitive employment; (ii) eligibility
for services based solely on client choice, with no exclusion on the
Pre-vocational services use a traditional step-wise train and place
basis of work readiness, substance use problems, lack of motivation,
approach for vocational rehabilitation. In this model, comprehensive
treatment non-compliance and so on; (iii) rapid job search upon
150 PSYCHIATRIC REHABILITATION PSYCHIATRIC REHABILITATION 151

programme admission using the ‘place then train’ approach; (iv) Another example from the Psychiatric Rehabilitation Unit of
attention to client preferences in the job search, rather than National Institute of Mental Health and Neurosciences (NIMHANS),
dependence on job availability; (v) close integration between the Bangalore is that of Individual Placement and Support (IPS) model
employment services and the mental health treatment team; (vi) of Supported Employment. The programme is in the beginning phase
ongoing, individualized support and job training after clients obtain with few clients being employed in competitive jobs. The process
employment and; (vii) systematic benefits counseling. was made successful through the involvement of an NGO which is
Indian Context working for the placement of Persons with Disability. By collaborating
with them, the Psychiatric Rehabilitation team of NIMHANS could
Even though there are no specific models that have been widely
identify jobs according to clients’ preferences and follow ‘place and
experimented, the approaches used by various organizations and
train’ approach. There is continuous and close integration between
professionals working in the field of psychiatric rehabilitation in India
are similar to those explained above. Due to practical difficulties of the employment service provider and the psychiatric social work team
adopting a specific model, professionals follow a mixed approach where the team members make frequent visits to the workplace and
when rehabilitating the clients. The existing facilities for psychiatric provide individualized support to the clients. The team members also
rehabilitation in India are very few in number where most of the meet the job supervisor and discuss workplace solutions to make
programmes are associated with the hospitals providing mental health accommodations in the work. The clients also visit the hospital for
services. This makes it difficult for the professionals to engage in their regular clinical follow up.
systematic vocational rehabilitation. Even though there are no specific models or literature on home
The mostly followed vocational rehabilitation efforts in India are based vocational rehabilitation, Pillai et al (2010) reported that
either sheltered workshop or traditional vocational rehabilitation even educating patients and their care givers about simple home based
though they are not named so. Both can be seen in private or rehabilitation practices that can be carried out in homes is effective.
government hospitals and Non-Governmental Organizations (NGOs) In this process learning the basic principles of work-behavioural
through their day care programme or residential services where they management, identifying and giving various activities in home and
engage clients in meaningful activities and encourage them to get supportive handholding given to the patient and caregivers by
into a competitive employment. Some of the clients continue to be in professionals, paraprofessionals or trained volunteers can help the
the sheltered workshops due to the severity of disability and other patient in rehabilitation and economic empowerment of the individual
challenges in entering regular job market. National Institute of Mental and the family.
Health and Neurosciences (NIMHANS), Bangalore has set an
example by engaging patients in workforce of the hospital, and thereby Conclusion
helping holistic rehabilitation of the individual and family both financial In India, stigma attached with mental illness is still present in the
independence and treatment of the clients. This could be followed by society which comes as a major barrier for employment or vocational
other mental health service providers as the stigma attached with rehabilitation of persons with mental illness. As a first priority, the
mental illness is still present in the society and it comes as a major mental health professionals can work towards identifying job/income
barrier for employment of persons with mental illness. generation activities for the clients in the hospital premises itself or
 152 PSYCHIATRIC REHABILITATION PSYCHIATRIC REHABILITATION 153

provide home based rehabilitation options that are feasible and References:
affordable for the clients. Since the manpower in the area of mental • The International Center for Clubhouse Development
health and rehabilitation are not matching with the current needs of (2004).Clubhouse Employment Manual. New York Work
the society, identifying job markets and influencing the policies of Exchange: Coalition of Voluntary Mental Health
employment providers through an employment specialist or placement Agencies, Inc.
officer can be kept as second priority. Vocational rehabilitation of
people with mental challenges can be made successful with the
• Farrell, S. P., &Deeds, E. S. (1997).The clubhouse model
as exemplar: Merging psychiatric nursing and
commitment and dedication of rehabilitation professionals, motivation
psychosocial rehabilitation. Journal of Psychosocial
and involvement of patient and family members, and acceptance and
Nursing and Mental Health Services,35(1):27-34
inclusion of mentally challenged to the workforce by the employers.
_______________ • Royal College of Psychiatrists.(2002).Employment
*
opportunities and psychiatric disability. Council
PhD Scholar,
**
Associate Professor Report CR111, London: Royal College of Psychiatrists.
Department of Psychiatric Social Work
National Institute of Mental Health & Neurosciences, Bangalore. • Mental Health Council of Australia.(2007). Let’s get to
work. A national mental health employment strategy
for Australia. Melbourne: Mental Health Council of
Australia.
• Marrone, J. F., Follwy, S., & Selleck, V. (2005). How
mental health and welfare to work interact: the role of
hope, sanctions, engagement, and support. American
Journal of Psychiatric Rehabilitation, 8:81-101.
• Waghorn, G., Lloyd, C., & Tsang, H. W. H. (2010).
International Encyclopedia of Rehabilitation,
Vocational Rehabilitation for People with Psychiatric and
Psychological Disorders. New York. Center for
International Rehabilitation Research Information and
Exchange (CIRRIE).
• Liberman, P. R. (2012). Recovery from Schizophrenia:
form follows functioning. World Psychiatry, 11 (3): 161-
162
• Kumar, S. P. N. (2008). Impact of vocational rehabilitation
154 PSYCHIATRIC REHABILITATION PSYCHIATRIC REHABILITATION 155

on social functioning, cognitive functioning and • Bond, G. R., Drake, R. E., & Becker, D. R. (2008).An
psychopathology in patients with chronic schizophrenia. update on Randomized Controlled Trials of Evidence –
Indian Journal of Psychiatry, 50:257-261. Based Supported Employment. Psychiatric
• Corrigan, P. W., Larson, J. E., &Kawabara, S. A. Rehabilitation Journal, 31 (4): 280-290
(2007).Mental illness stigma and the fundamental • Bond, G. R., Salyers, M. P., et al. (2007). A Randomized
components of supported [Link] Controlled Trial Comparing Two Vocational Models for
Psychology, 52:451-457. Persons With Severe Mental Illness. Journal of
• Rossler, W. (2006). Psychiatric Rehabilitation Today: An Consulting and Clinical Psychology, 75 (6): 968–982
Overview. World Psychiatry. 5 (3): 151-157
• Rinaldi, M., &Perkins, R. (2004).Vocational Rehabilitation
Psychiatry, 3:54-56.
• Rinaldi, M., &Perkins, R. (2007).Comparing employment
outcomes for two vocational services: Individual
placement and support and non-integrated pre-vocational
services in the [Link] of Vocational
Rehabilitation, 27:21-27.
• Corbiere, M., &Lecomte, T. (2007). Vocational services
offered to people with severe mental illness. Journal of
Mental Health, 16:1-13.
• Official website of Clubhouse International (http://
[Link]/[Link]) – Creating Community:
Changing the World of Mental Health.
• Bond, G. R. (1994). Vocational Rehabilitation. In:
Liberman, R. P, ed. Handbook of Psychiatric
Rehabilitation. New York: Macmillan, 244-75
• Becker, D.R., & Drake, R.E. (2003).A working life for
people with severe mental illness. New York: Oxford
University Press.
• Bond, G. R. (2004). “Supported employment: Evidence
for an evidence-based practice”. Psychiatric
Rehabilitation Journal, 27 (4): 345–359.
156 PSYCHIATRIC REHABILITATION PSYCHIATRIC REHABILITATION 157

PSYCHIATRIC REHABILITATION • The PRS only admits those individuals whose needs can
SERVICES – A NURSING ORIENTATION be met by the facility.

* • Ideally there should be a written agreement between the

Sailaxmi Gandhi
patient and the PRS. The agreement specifies the services
Introduction: to be provided by the facility, scheduled days, financial
Psychiatric Rehabilitation Services (PRS) are supportive services arrangements, transportation agreements, emergency
meant for symptomatically less active patients who require social procedures and conditions for discharge. This is signed
and vocational rehabilitation. Out-patients can get admitted here or by the patient, (if s/he is able to) and family member.
in-patients may be referred for psychiatric rehabilitation. This takes
Plan of Care:
care of the day care needs of the psychiatrically ill who are functional
otherwise. After establishing rapport with the patient, initial assessment is
done. Assessment focuses on mental status examination, social skills
Who can avail psychiatric rehabilitation services?
assessment, disability assessment, history, previous rehabilitation
Anyone with mild and moderate intellectual disability and mental attempts, treatment history, vocational interests and abilities, education,
illness inclusive of the following diagnoses by a psychiatrist: family support system, family involvement with the patient, family
schizophrenia, major mood disorder, psychotic disorder NOS, emotional climate and patient motivation level. Based on the initial
schizoaffective disorder or borderline personality disorder. As a result assessment, a preliminary written plan of care is developed for each
of the mental illness, the person may have a mild to severe functional
patient. The plan is based on a functional assessment and information
impairment that interferes with or limits role performance in at least
obtained from the patient, family, and the referring unit/agency. The
one of the following domains: educational (i.e., obtaining a high school
plan can include: A description of the patient’s needs; the activities,
or college degree); social (i.e., developing a social support system);
programming and services in which the patient will participate in order
vocational (i.e., obtaining part time or full time employment); self
maintenance (i.e., managing symptoms, understanding their illness, to meet those needs; and realistic goals for the patient, designated
managing money, living more independently) relative to the person’s roles of the responsible staff and when appropriate, the timeline for
ethnic/cultural environment. The person and family members who each goal. The ultimate goal is decided based on the patient’s interests
are willing to participate in the rehabilitation process and use their and abilities, families’ requirements and the team’s assessment of
time, money, talent/abilities and energy productively can avail the the patient.
facilities in the psychiatric rehabilitation services. Plan should be reviewed at regular intervals with the patient and
Criteria for the PRS family member and revised if needed. The revision should take place
• The PRS has written admission policies which describe in consultation with the patient and family members. The patient and
admission and discharge procedures. family are oriented to all the various services provided by the PRS
and then choice is given to the patient to choose the section (domestic
• The admission policies are discussed with each patient
section, tailoring, bakery, etc.) she/he wishes to be trained in.
and the family member.
158 PSYCHIATRIC REHABILITATION PSYCHIATRIC REHABILITATION 159

Depending on the patient’s abilities, independent living skills (basic Types:

and instrumental), social skills, supported education services, domestic
a. Basic Activities of Daily Living (BADL)
skills and work habit formation are included as part of the program
planned for the patient. The patient and family member are instructed b. Instrumental Activities of Daily Living (IADL)
not to bring sharp instruments and valuables while attending PRS. a. Basic Activities of Daily Living (BADL):
Activities of daily living and independent living skills of These are self-care tasks such as:
mentally ill clients
• Personal hygiene (Brushing, bathing, combing)
Psychosocial rehabilitation aims at long term recovery and
• Grooming
maximum self-sufficiency for mental health service users. It differs
from acute care which focuses on symptom control and traditional • Dressing and undressing
forms of treatment which include medication and psychotherapy. • Self feeding
Psychosocial rehabilitation does not exclude these aspects but
expands to include ways to foster social interaction, to promote • Bowel and bladder management
independent living, and to encourage vocational performance. The James (2008) suggests that BADL “is typically restricted to
focus is on teaching skills and providing support so that the individuals activities involving functional mobility (ambulation, wheelchair mobility,
with psychiatric disabilities can function in social, vocational, bed mobility and transfers) and personal care (feeding, hygiene,
educational and familial roles of with the least amount of supervision toileting, bathing and dressing)”. For mentally ill patients, these
from the helping professionals. The term ‘Activities of Daily Living’ activities refer more to self-care activities in the second part of this
(ADL) is used in rehabilitation as an umbrella term relating to self- definition i.e. personal care.
care, comprising those activities or tasks that people undertake
b. Instrumental Activities of Daily Living (IADL):
routinely in their every-day life.
These are activities that require higher level of skills such as
Meaning:
judgment, decision making, abstraction, comprehension, etc. Activities
Activities of daily living (ADLs) is a term used in healthcare to such as cooking, shopping, managing money, housekeeping, etc. also
refer to daily self-care activities within an individual’s place of require these higher cognitive skills. Katz, (1983) stated that
residence, in outdoor environments, or both. Health professionals “...instrumental activities of daily living functions are concerned with
routinely refer to the ability or inability to perform ADLs as a a person’s ability to cope with her/his environment in terms of such
measurement of the functional status of a person, particularly with adaptive tasks as shopping, cooking, housekeeping, laundry, use of
regard to people with disabilities and the elderly. transportation, managing money, managing medication and the use
of the telephone”
Definition:
History:
ADLs are defined as “the things we normally do...such as feeding
ourselves, bathing, dressing, grooming, work, homemaking, and 1935: The first reference to activities of daily living was reported
leisure.” by Sheldon in the Journal of Health and Physical Education.
160 PSYCHIATRIC REHABILITATION PSYCHIATRIC REHABILITATION 161

When reviewing the Medline data base it was found that the 2. Assessment of ADL:
term ADL was first used as a subject heading or indexing term in • The Katz Index of ADL (Katz et al. 1963), the Barthel
1968 (Index Medicus). Prior to this date, the construct was indexed Index (Mahoney &Barthel, 1965), the Kenny Self-Care
as Rehabilitation related to self-care. Evaluation (Schoening et al. 1965) and the Self-maintaining
1969: Lawton and Brody were the first authors to describe two and Instrumental ADL tools (Lawton and Brody 1969)
levels of activities of daily living. • International Classification of Functioning Disability and
The ICF was developed by the World Health Organization to Health (ICF) (World Health Organization, 2001), the
provide a comprehensive framework of definitions and structures Personal Care Participation and Resource Tool (PC-
for rehabilitation. PART) (Darzins 2004)

The ICF views a health condition or disease as the interaction of The table below gives a sample of independent living skills:
body function and structures, activities and participation, which are
in turn impacted on by social and environmental factors.
Goal of the PRS team:
The PRS team aims to achieve maximal increase in function and
participation in every-day life for the patient or client by intervening
in the areas of BADL & IADL.
1. Assessment of ADL:
ADL evaluations can be used to –
• Provide an overview of functional status
• Determine activity limitations
• Establish a baseline for treatment
• Provide a guide for intervention planning
• Provide a guide for reporting and data management
• Evaluate intervention programs and monitor progress
• Plan for the future and for discharge
• Measure outcomes of rehabilitation
• Provide data for Evidence Based Practice
162 PSYCHIATRIC REHABILITATION PSYCHIATRIC REHABILITATION 163

Important Tips: They facilitate communication, help improve rehabilitation services,

aid in meeting professional and legal standards and are necessary for
The therapist/caregiver requires a lot of patience and persistence
future reference and verification. Documentation helps meet NABH
while training the mentally ill person in BADL & IADL. One has to
(National Accreditation Board for Hospitals & Healthcare Providers)
use very simple words, single sentences, one instruction at a time
requirements that form a part of quality control.
and keep reinforcing the patient whenever he demonstrates correctly
the learnt skill. Various records maintained at PRS: Records of various activities
related to psychiatric rehabilitation services, academic activities,
Teaching strategies such as role play, demonstration, video administration and research work are maintained at the PRS. These
demonstration, and problem based learning, etc. need to be used to are as follows:
facilitate better learning. Verbal and non-verbal communication plays
1. Records of psychiatric rehabilitation services: Admission
an important role here.
and discharge register, patient activity schedule, patient bus
Tasks have to broken up into micro-tasks and then taught. attendance, independent skill living, leisure activity, patient
Gradually more complex steps can be taught. Behavioural techniques contact details, incentives, section attendance, PRS OPD
such as use of cues, chaining, repetition, rewarding can be used. register, OPD referrals, ward referrals, patient census,
Initially token re-enforcers in the form of eatables, articles favoured investigations, treatments, patient weekly weight record, patient
by the patient may be given and gradually switch on to social re- placement register, cultural programs register and patient
enforcers such as eye contact, patting, smiling etc. incident register are some of the psychiatric rehabilitation
services related records that are documented and maintained.
As training in ADL can take a long time, the therapist has to be
satisfied with and reward micro gains (i.e. small steps successfully 2. Records of academic activities: Student posting register,
carried out, e.g. holding a tooth brush correctly). Initial hand holding workshops, conferences, symposiums, training program
records, teaching activities, etc.
may be necessary and gradually the therapist/care giver can let go
as the patient becomes independent. Always include the family 3. Records related to administration of PRS: Staff meeting
member while teaching these skills to the patient. minutes, circulars, leave registers, staff communication books,
file lending registers, list of files sent to the medical records
Ultimately they need to carry on this training at home on a long
department, lift maintenance, central sterile supply register,
term basis at times. The ‘Family as equal partners in treatment’
laundry register, biomedical repairs register, indent of hospital
concept is emerging today. This time can also be utilized to address necessary supplies, medicines, equipment, condemnation
burden issues of caregiver. registers, fire extinguisher maintenance, aqua guard water
Documentation safety microbiology reports, invoices, are a few records related
to administration.
At times one finds that a lot of work may have been done but
unfortunately not documented. However, documentation of services, Points to keep in mind related to documents:
information, meetings, etc serve as a record and stand alone evidence. • Document immediately after the action, incident,
Documentation and recording are very important components of PRS. intervention etc.
164 PSYCHIATRIC REHABILITATION PSYCHIATRIC REHABILITATION 165

• Document completely and accurately What has to be documented?

• Be neutral while documenting Apart from the various records and reports maintained in the
• Note the time and date while documenting PRS facility that need to be maintained up to date, patient services
need to be documented accurately. Type of interventions attempted
• Sign clearly mentioning the name following each
in patients, patient and family response, medications that have failed
documentation
or led to toxic side effects, placement trials, patient behaviour, contact
• Write clearly and legibly details of philanthropic organizations which offer placement
• Do not overwrite opportunities for psychiatric patients, self-help groups contact details,
reasons why certain modalities of treatments were rejected, patient
• Do not strike off untidily or try to squeeze new content in
between and family compliance with vocational rehabilitation, etc. are some
of the more important details that need to be documented meticulously.
• Maintain all related registers and records up to date.
Ethical issues:
Points to keep in mind related to records:
All patient related documents and records are to be maintained
• Have adequate knowledge about hospital policies
and stored carefully. Unauthorized persons are not allowed to have
regarding maintenance of records
access to them. Information should be kept confidential and used
• Keep the records in a place accessible only to the health only for treatment or placement purposes. No information should be
care team shared with media or other services however well-meaning their
• Take permission from the treating physician in case a intentions without consent from the patient and the family member.
person other than the treating team wishes to read a
Documentation is an evidence base which can support psychiatric
record
rehabilitation services. It helps review of work done, evaluation of
• Ensure complete maintenance of records accurately services, quantify work done, evaluate effects of new rehabilitation
• Ensure prompt recording of reports interventions, helps orient novice personnel such as volunteers, student
• Prepare reports which are clear, concise, accurate and trainees, etc. All documents and records need to be preserved in a
objective place that is secure and easily accessible to authorized persons.

• Communicate oral reports clearly, accurately and record Discharge:

in the file Discharge from the Psychiatric Rehabilitation Services must be
• Make accurate entries in the communication book planned if:
• Maintain confidentiality while giving reports 1. There is a reasonable expectation that the withdrawal of
services will not result in loss of rehabilitation gains or goals
• Report problems related to supplies and equipment
attained by the patient.
• Report critical incidents to the concerned authorities
166 PSYCHIATRIC REHABILITATION PSYCHIATRIC REHABILITATION 167

2. The patient has successfully achieved rehabilitation goals and References:

sustained them for a period of time as designated in the • Bennet H Douglas, Freeman L Hugh. Community
rehabilitation plan psychiatry: The principles. New York: Churchill
3. The patient or family wishes to voluntarily terminate from PRS Livingstone; 1991. P.386-410.

4. No further improvement is expected by the team • Cohen M, Mynks D. Compendium of activities for
assessing and developing readiness for rehabilitation
Discharge should be planned well ahead. The patient and family
services. Boston: Center for Psychiatric Rehabilitation;
should be prepared in advance. Treatment compliance and family
1993.
emotional climate needs to be assessed prior to discharge. Patient
and family psycho-education has to be part of the discharge plan. • Community Psychiatric Rehabilitation Program (CPRP).
Prior notice should be given by the PRS team to the patient and BJC Health care. Available from: BJC Behavioral Health
family, if any. At times depending on the patient condition, the discharge - Community Psychiatric Rehabilitation Program
may have to be done without much notice. The patient and family (CPRP).htm
can be given the choice of continuing follow up care at the PRS. • Fricke J. 1993. Measuring outcomes in rehabilitation: A
Both admission and discharge needs to be documented in all the review. British Journal of Occupational Therapy
relevant registers. Suitable advance needs to be deposited at the 56(6):217-221.
time of admission and account settling has to be done at discharge.
If the patient has been placed in a vocational service, it would ideally
• James AB. 2008. Activities of daily living and instrumental
activities of daily living. In: Crepeau EB, Cohn ES, Schell
benefit the patient if the PRS or the social work team periodically
BB, editors. Willard and Spackman’s Occupational
reviewed the patient’s progress with the employing agency.
Therapy. Philadelphia: Lippincott, Williams and Wilkins.
Conclusion: p 538-578.
Rehabilitation is a slow process. However, it is possible to achieve
• World Health Organization. 2001. International
maximum functional capacity when the patient, family, the PRS team,
classification of functioning, disability and health (ICF).
government and society work towards these goals.
Geneva, Switzerland
_______________
* Assistant Professor, Department of Nursing • Anthony A. Menditto, Charles J.,Wallace , Robert P.
National Institute of Mental Health & Neurosciences, Bangalore.
Liberman, Jillon Vander Wal , et al Functional Assessment
of Independent Living Skills. Psychiatric Rehabilitation
Skills, 3:2, 200-219
168 PSYCHIATRIC REHABILITATION PSYCHIATRIC REHABILITATION 169

COMMUNITY BASED REHABILITATION a. Mental health care and societal beliefs

FOR PEOPLE WITH MENTAL ILLNESS: Mental health care has always been influenced and determined
FIELD EXPERIENCES OF MENTAL by contemporary beliefs. Traditionally, mentally ill people in
HEALTH AND DEVELOPMENT many countries were cared in temples and other religious
institutions, based on the belief that mental illness is a form of
PROGRAMME IN INDIA spiritual affliction and could thus be cured by religion.
*
Janardhana N, Superstition combined with inadequate mental health services
**
Naidu. D.M, in the community have left people with mental illness subject
***
Nirmala. B. P to physical abuse in the name of treatment by black-magicians,
Introduction: village quacks and witches. Often people with mental illness
are kept outside the margin of the community: chained up,
Through out the world people with mental illness are denied their
locked in back rooms, wandering in the streets, shut away in
basic human rights, especially the right to access treatment, closed wards of asylums, hospitals, etc. In many countries
rehabilitation and appropriate mental health care. People with mental mental health issues are not part of public health or rehabilitation
illness and their families experience discrimination and exclusion from
programmes.
economic and social activities. Due to the stigma, people with mental
illness and their families are often ridiculed and isolated, trapping b. Stigma and Discrimination
them in a cycle of poverty. A lack of access to information about People with mental illness live with stigma which often results
their rights and support to exercise these rights perpetuates and in the abuse of their human rights. This stigma often times
deepens this marginalization. People with disabilities also experience includes isolation of the person’s family as well.
stigma, discrimination and social exclusion. However, the situation, in
Mrs. K, middle aged mother of two children lives in a
the case of people with disabilities has improved in many countries
village in North India. Her husband is a rickshaw puller
through CBR initiatives. Including people with mental illness having
with meagre income. Mrs.K developed depression because
psychosocial disabilities in CBR programme seems an ideal answer
she and her husband were unable to sustain the family.
to address the needs and rights of people with mental illness along
Quite religious by nature, she believed that God would
with other people with disabilities.
change the scenario one day. To support her belief she
Goal of inclusion of people with mental illness in the CBR never missed attending the village temple. But days
programme: passed and her family became poorer leaving her more
People with mental illness participating in society and having depressed and desperate. She started to stay in temple
access to generic services as well as appropriate support they may for hours and neglected her family. Unable to identify
require and which they consent to. her illness and suspecting that she was practicing
Ground realities: witchcraft and could harm the children in the village, the
170 PSYCHIATRIC REHABILITATION PSYCHIATRIC REHABILITATION 171

villagers threatened her husband. The husband was not • Legal separations
able to halt his wife’s religions fervour. The husband and
• Women with mental illness bear the brunt
other family members were continuously harassed.
Ultimately, the villagers isolated the family, denying them • Family members not getting marriage alliance and isolated
access to all the services and facilities of the village. The Ms.S, a woman with mental illness, lives with her brother
family was not even allowed to draw water from the village and sister-in-law. Her parents are no longer alive. The
well. family lives in abject poverty and work as daily wage
The story above is not an isolated incident. It is the fate of many labourers. They will have no food to eat if either the
people with mental illness all over the world. Most people with mental brother or his wife stay athome to care for S. one day, to
illness live at home without any treatment because their families don’t their shock and dismay, they discovered that S was
recognize the illness or they are embarrassed to be recognized as pregnant. They later found out that she was sexually
related to someone who is mentally ill (in many places commonly abused by a local doctor. Before the local NGOs could
called ‘mad’). The very thought of someone in the family getting file a case against the doctor, he covered it up by giving
mentally ill is a big shock and people do not want to believe it. Hence some monetary compensation to the family and paying
family members first go to temples, black magicians, witches and for an abortion.
faith healers, wasting financial and other resources. Family members
often fear they will be disgraced and will lose the status and Mr. M, a brilliant student , failed in his 2nd year pre-
acceptance they enjoy in the community. The stigma is such that university exam. Since then, he started wandering in the
people feel ashamed and deny the illness. Stigma is the first and forests and became so violent that his own siblings were
foremost element that shrouds the realm of mental illness. scared of him. Because of his behaviour, the community
Due to stigma, people with mental illness become victims of suggested his parents to throw him out of the house on
discrimination and human rights abuse. The discrimination is seen the streets. The family instead decided to lock him up in a
from the family members and goes right up to the policy makers and room and manacle his legs and hands. Mr.M was left to
state authorities. The general attitude of the public is that of apathy. do everything(eating, shitting, sleeping) in the room. His
father used to carry the shit with his hands. The whole
Discrimination manifests in many ugly, inhuman and
family was stigmatized. Their home was called the mad
humiliating forms:
person’s home. Nobody showed interest in fixing up
• Physical and sexual abuse analliance with his family. The engagement of a family
• Harmful treatment such as chaining and locking up in member was broken because of the stigma.
rooms
• Social isolation of both the individual and the family
• Denial of property of rights
172 PSYCHIATRIC REHABILITATION PSYCHIATRIC REHABILITATION 173

Mrs. L aged 38, married, developed mental illness. The POVERTY AND MENTAL ILLNESS
husband left her believing that she brought ill luck to the
family. Having no parents she became a destitute. Even
the relatives disowned her. She was wandering in the
streets, some times without cloths on her. She suffered
physical pain because of stone throwing by children. She
was also sexually abused. She survives picking up
eatables from the garbage.

People with mental illness are treated as second-class citizens

with no adequate facilities or provision from the government. As a
result, they face chronic ill health and the families experience
economic and social burdens. In certain cases this leads to social
destitution. Mr. C, aged 50, had suicidal tendencies. He tried to drown
a. Poverty and Mental Illness himself and to electrocute himself. Luckily, there was
People with mental illness are not only vulnerable due to their someone around and he was saved both the times. Mr
condition, but also because they are poor. Poverty can be both a C’s family spent a lot of money for his hospitalization
consequence and to some extent a cause of their condition. One of and medicines. He stopped eating, and does not talk to
the main reasons that people find it hard to accept others with mental anyone. The family became poorer and poorer. Mr. C’s
illness as equal members of their communities is that they do not see health status meant his family had to have someone by
them as capable of contributing to the household or the community. his side all the time. His wife worked day and night to
For decades, researchers have shown that poverty and mental illness make ends meet. Lakshmi, his daughter discontinued her
are correlated; the lower a person’s socio-economic status, the greater studies so that she could care for her father.
his or her chances are of having some sort of mental disorder. Poverty a. Mental illness and disability:
exacerbates mental illness. It is this vicious circle that community If a person is unable to perform an activity because of disease/
based mental health services aims to break; illness or due to bodily impairment, the person is considered as
disabled. Though psychiatric disorders do not cause any physical
impairment, they can stop people from doing many activities that are
expected of them. The disability in psychiatric illnesses is dynamic
being influenced by the nature of illness, phase of the illness, treatment
status and social support network available to them. All people with
mental illness do not develop psychosocial disabilities. People with
174 PSYCHIATRIC REHABILITATION PSYCHIATRIC REHABILITATION 175

Psycho-social disabilities are unable to maintain personal hygiene; Indicators of readiness

experiencing difficulties in interpersonal relationships and the In order to begin a mental health component in the CBR
communications; inability to participate in social functions and the programme, the following readiness indicators should be demonstrated:
roles; and finding difficulties in engaging in productive activities.
1. Organization’s willingness to work with mental illness
Community Based Rehabilitation and people with mental
illness 2. Basic understanding of the mental health concept/
problem
Development and changes in the concept of CBR over the last
two decades has influenced the thought of inclusion of mental health 3. A match of context between current CBR activities and
in CBR programmes. The CBR strategy shifts rehabilitation mental health and development needs
interventions to homes and communities of people with disabilities. 4. Resource stability of the organization
Basic services are provided or facilitated by CBR workers who are
Inclusion of mental health into CBR:
minimally qualified non professionals but who are highly qualified
change agents. The main goal of rehabilitation has become broader There are a number of reasons why mental health should be
and focuses beyond the individual, to the family and communities in integrated into community based rehabilitation programmes:
which people live. CBR recognizes that, breaking barriers to inclusion • Community processes, full participation, equal
in society is important mission of the CBR programme and in the opportunities, social inclusion, gender, diversity and a focus
functional rehabilitation of individuals with disabilities. Thus the on rights are some of the key common elements of CBR
universal mission of CBR is: work. Community mental health work is no different so
1. To enhance activities of daily life of disabled persons the programmes integrate well together.

2. To create awareness in disabled person’s environment • The high prevalence of psychosocial disabilities emerging
to achieve barrier free situations around him and help through mental illness and its impact on communities,
him in meeting all human rights. societies and economies means that CBR workers are
confronted with the issues in their work. CBR
3. To create a situation in which the community of the
programmes can have a positive impact on the lives of
disabled persons, participates fully and assimilated
people with mental illness, their families and on the
ownership of their integration in to the society. The
situations in which people live by including people with
ownership lies in the affected persons.
psychosocial disabilities in their programmes.
The above mission is no exception for people with mental illness.
• There are a limited number of mental health professionals
CBR programmes can link with mental health professionals, users of
and mental health services in low-income countries,
mental health services, DPOs and SHGs to broaden the scope of the
making a CBR strategy which empowers community level
CBR programme to include people with psycho social disabilities and
stakeholders to take action an important strategy.
to promote community mental health services.
176 PSYCHIATRIC REHABILITATION PSYCHIATRIC REHABILITATION 177

• The emerging trend away from vertical health 7. Inclusion would ensure coverage of all people with
programmes to integrated, multipurpose health programme disabilities.
models favours primary level services and community 8. Mental health problems of people with disabilities are
based strategies. addressed, which adds value to the existing CBR
• There is an increasing recognition of the importance of programme.
early detection and treatment of mental illness in order to 9. An environment would be built where in all disadvantaged
prevent chronic conditions. groups including people with mental illness fully participate
• The goal of continuity of care and inclusion of people in their own development and the community in which
they live in.
who are mentally ill into the community is more readily
achieved when there is an existing community based Some of the important roles of the CBR and the community
strategy. development work force are:

• The prevalence of mental health problems among people a. Awareness raising and dissemination of information;
with other disabilities means that a mental health b. Identification of people with mental health problems and
component in the CBR programmes brings added value. referral to health services;
Advantages c. Crisis support;
The advantages of including people with mental illness in d. Home based support-supportive care, including basic
existing CBR programmes are: information and counselling;
1. Meeting the needs of most disadvantaged group. e. Helping with the activities of daily living skills and
community reintegration;
2. This promotes faster integration of people with mental
illness into the mainstream societal activities. f. Formation of caregiver groups/associations;
3. Promotes good mental health in the community and leads g. Advocating for the rights of people with mental illness;
to early identification. h. Preventive and promotive services;
4. Inclusion of people with mental illness in CBR programme i. Organizing affected people to advocate for meeting their
would be cost effective. needs.
5. CBR strategies and approaches very much fit in meeting The care for people with mental illness can be provided by :
the needs of people with mental illness.
• Family members providing care to people with mental
6. Encourages innovative use of the resources that already illness starts from baring all the violent behaviour, to
exist (for example street theatre troops, advocacy groups, accompanying them for treatment, than administering
etc.) medicines, helping to engage in gainful productive work.
178 PSYCHIATRIC REHABILITATION PSYCHIATRIC REHABILITATION 179

• Community providing support for the well-being of people

Caregivers Associations
with mental illness. This is seen in the form of not calling
them as mad people, giving opportunities and advocating People with mental illness and their caregivers are
for the ensuring measures to meet the needs of people encouraged to form an association of their own. This
with mental illness. provides a platform for them to discuss various problems
they share and find solutions. For example, Mr B’s, family
• Rehabilitation workers providing care for the people with
experienced unwelcome reactions of neighbours towards
mental illness and their families. This starts with
their son. Mr B was wandering in the streets and his
identification, assessment, follow up, home based support
parents had to find him and bring him back. The
and linking them to existing groups and mainstreaming.
caregivers’ association in the village took the
• Organization providing support to deal with other responsibility to explain the illness to others. Mr B has
associated problems of people with mental illness and now returned to work as a labourer and is maintaining
their caregivers. This is seen in the form of conducting full-time employment.
camps, integrating them in to their existing programmes.
Another caregivers association took the decision to
• Provided with the above support, the role of mental health advocate for their right to treatment. The association
professionals would be more meaningful. members met the district authorities, explained to them
Mr. M, a young volunteer from a youth group in Jalahalli, the need for treatment to be made available at their block
took initiative to support a woman who is mentally ill level. People with mental illness and their families decided
and destitute in his village. He witnessed a shop keeper to voice their needs rather than depending on the local
physically abusing (pushing) her for entering his organizations. This resulted in the deputation of a
restaurant. Mr M took this abuse seriously. With the help psychiatrist to conduct mental health camps in the local
of an NGO he took her to a mental hospital for treatment, health care centres on a monthly basis, with medicines
following guidelines of Mental Health Act for the being distributed during these camps.
involuntary admission. After her discharge, he spoke with
the woman’s relatives and made arrangements for her Street theatre
stay and livelihood. People like Mr M, volunteer to
Street theatres play a major role in generating awareness
support NGOs in their work. NGOs also experience
in the community. Some organizations also have formed
stabilised people playing the role of volunteers and
puppet shows troops. Street plays can provide knowledge
advocates. Always people inspired by good work
on; causes, treatments and symptoms of mental illness.
voluntarily offer assistance.
The purpose is to demystify the subject and to raise the
awareness of the public on mental health issues. Street
180 PSYCHIATRIC REHABILITATION PSYCHIATRIC REHABILITATION 181

Include people with mental illness and their families in

theatres can also highlight the important roles and livelihood programmes
responsibilities of families and the community, which
A tale of market
could go long way in rehabilitating people with mental
illness. The street theatre performances can be followed Mr. S a beneficiary of the mental health programme
by question and answer sessions, where people can ask implemented by BasicNeeds India (BNI) partner in
specific questions. Tamilnadu shares his experience. S suffered from mental
illness but has now recovered sufficiently to be able to
Work with Disability People’s Organizations (DPOs) and run a small enterprise selling cooking ingredients on his
service users to advocate for access to treatment bicycle. He rides about 35 kilometres per day on a regular
set of routes and has built up a network of established
The community based organization, SACRED, included
customers. At the outset, he spent a good deal of time
mental health programme in to their existing CBR
working out the various ingredients that were likely to be
programme. People with mental illness had to travel 100 in greatest demand, such as pepper and coriander, and
kilometres to attend the mental health camp conducted the quantities required. He sells small packets tailored
by the National Institute of Mental Health And Neuro exactly to the needs of low-income customers who
Science because there were no services available in that purchase their requirements daily and at affordable
district. With the support of the federation of people with prices. He earns 2 US dollars a day
disabilities, people with mental illness were successful in
sensitising the district authorities and advocating for the Before he became mentally ill, Mr V worked for 30 years
availability of mental health services with in the district. in the weaving industry. He gave it up and concentrated
Of course the struggle took more than three years. in overcoming his illness with the support of his family.
Following treatment and ongoing assistance from an
Similar experience in Koppal and Raichur districts, people NGO, he decided to set up a small business supplying
with mental illness and their caregivers were travelling 8 hours snacks to travellers using the bus shelter in his village.
to reach Karnataka Institute of Mental Health, Dharwad for He starts preparing the food at 5.00am and sells from
assessment, diagnosis and treatment services. Organizations 8.00am until noon and than he rests. Trade has been
of people with disabilities promoted by CBR programme of consistently good and he earns 3 US dollars a day. This
Samuha have sensitised the authorities and successful in income although modest, is comparable to others in his
getting the services with in their district. Awareness building village. He describes himself as having a completely new
among family members and community complemented the beginning. He is confident and contented, enjoying the
efforts. relative freedom of the work that he does now. The local
village council was instrumental in his success, allowing
Mr V to use the bus shelter, which is a favourable location
for his business.
182 PSYCHIATRIC REHABILITATION PSYCHIATRIC REHABILITATION 183

Promote Community Mental Health Services

Self Help Groups
Mental health professionals in several low-income countries are
Self Help Groups are a common feature of CBR and
actively promoting Community Mental Health (CMH) and are
development work. A self-help group of women were
attempting to influence their governments to initiate measures to bring
clearly working hard to be strong in the face of personal
mental health into the primary health care system. CBR programmes
tragedy and unrelenting poverty. Comprising twelve
can work with mental health professionals, local health centre staff
members, they came together with the support of CBR
and users of mental health services to promote community mental
worker to promote savings of Rs.100 per month per
health services. Many mental health problems can be effectively
person so that individuals can accumulate enough to buy
resolved by working together with people who experience mental
a buffalo. This would then be a source of regular income,
illness in their own homes and communities and using resources and
the milk being sold to a cooperative at a guaranteed rate
support networks that are available to them. Awareness raising
per litre. One of the women had lost her husband to a
campaigns and large-scale dissemination of knowledge and skills
snakebite the previous week and so the group was rallied
would help in reducing the stigma attached to illness. Building
around to support her and her three children.
knowledge and awareness among families can make the real
difference in ensuring that people with mental illness are integral The link comes from the member living with schizophrenia,
members of the family and community and are participating in all who has been accepted as treasurer for her literacy skills
social and cultural activities. (despite only having stabilised her schizophrenia during
Community Based Organisation (CBO) the previous year). And she also derives benefit as any
other marginalized member of the group. Together the
The project head during one of the meeting expressed group advocates for meeting the individual, group and
that because of inclusion of the mental health programme, community needs.
the credibility of the organization has increased, the
organization got more recognition in the community and This way they play an important role in integrating people
also in the district administration. The organization with mental illness in main stream and provide mutual
leaders were invited to become members of the support to people in crisis
government constituted boards. District authorities were
Seek out alliances for training and mutual support
appreciative and requests were received to extend mental
health services to other parts of the district Local community organizations staffs like community rehabilitation
workers/field staffs, coordinators of self-help/user groups and other
programmes, lay volunteers/ animators, nurses, and health workers;
who are not professionals in mental health or health care provide a
variety of services. Many of these informal community-care providers
have little or no formal mental health care training, but in many low
184 PSYCHIATRIC REHABILITATION PSYCHIATRIC REHABILITATION 185

income countries they are the main source of community mental health of mutual understanding can be built, where in people with mental
provision. They are usually accessible and generally well accepted in illness enjoy their rights.
local communities. They can help with the integration of people with Conclusion:
mental disorders into community activities and the other developmental
activities of their own organizations, and thus play an supportive role It has been tested and proved that inclusion of mental health
in meeting the treatment needs of people with mental illness. issues in CBR programmes is possible, cost effective and help building
an environment where in people with all disabilities access their
Broaden understanding of the issues entitlements and enjoy equal opportunities for full participation in their
Development practitioners need basic understanding of mental own communities.
disorders. This includes understanding the symptoms of mental _______________
*
disorders and how they affect the behaviour, need for treatment - Assistant Professor,
***
Associate Professor, Department of Psychiatric Social Work, National Institute of
medical and psychosocial interventions. It is essential to consult people Mental Health & Neurosciences, Bangalore.
**
Programme Manager, Basic Needs India, Bangalore.
with mental illness and their family members to listen to their
experiences, needs aspirations to understand that particular individual
and the family. Training can be provided in basic competencies, such
as counselling- listening and communication skills and the need to
maintain confidentiality, managing conflict of interests when dealing
with individuals as well as their families, maintaining a neutral stance
and dealing with disturbing emotions.
“The wounds that can not be seen are more painful than
those that can be treated by a doctor”- Nelson Mandela

The list of potential care providers should be moved up and the

following paragraph could possibly be incorporated into the conclusion
(except there needs to be more emphasis on the active role of the
individual with mental illness rather than an exclusive focus on the
family and community roles.
A different and better world for all people, including people with
mental illness can be created through community based mental health
services, where in the communities understand issues related to mental
health, resulting in positive response to the issues. In this scenario the
families of people who are mentally ill are vitally involved in bringing
change in the attitude of the community. Through these an environment
186 PSYCHIATRIC REHABILITATION PSYCHIATRIC REHABILITATION 187

References: • Sherer, R. A. (2002) Mental health care in the developing

• Christoffel Blindenmission - CBM. (2002) Mental Health world. Psychiatric Times, 19, 1.
Services in the Context of Community – Based • Shoba Raja, Director Policy & Practice, Basic Needs –
Rehabilitation. Policy Paper. CBM Policy Paper April CBR MH success indicators research study report
2002.
• UN Convention on the Rights of people with disabilities,
• Desjarlais, R., Eisenberg, L., Good, B., et al (1995) World New York UN 2006
Mental Health: Problems and Priorities in Low-income
• UN resolution 46/119, principles for protection of persons
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and developmental disorders: meeting the challenge in
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Sciences.
• Jacob, K. S. (2000) Community care for people with
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• Kohn, R., Saxena, S. Levav, I. and Saraceno, B. (2004)
The treatment gap in mental health care. Bulletin of the
World Health Organization, 82: 858-866.
• Maya Thomas and M.J. Thomas (2003) Manual for CBR
planners, Asia pacific Disability Rehabilitation Journal.
• Patel, V. and Kleinman, A. (2003) Poverty and common
mental disorders in developing countries. Bulletin of the
World Health Organization. 81: 609-615.
• Ranjith and Duddu, V. (2001) Psychiatric services in
developing countries. British Journal of Psychiatry. 179,
368-369.
• S Pruthvish (2006) Community Based Rehabilitation of
persons with Disabilities, Jaypee publishers
188 PSYCHIATRIC REHABILITATION PSYCHIATRIC REHABILITATION 189

REPORT ON ONE MONTH were able to understand the problems of the mentally-ill identify the
ORIENTATION PROGRAMME IN resources and in many cases they have come out with solutions in
managing the mentally-ill in the community. The field visits to various
PSYCHIATRIC REHABILITATION NGOs and governmental organizations were mutually beneficial both
SERVICES to the trainees as well as the department as it served dual purpose of
A one month orientation programme for health care professionals exploratory as well as follow-up of the patients whom we have placed
on psychiatric rehabilitation was organized by the Psychiatric in their organization. The one month orientation programme was
Rehabilitation Services unit of NIMHANS in the month of August winded up on August 31st, 2012 following a post feed back session.
2012. The programme was meant for the health care professionals LIST OF CANDIDATES REGISTERED FOR ONE MONTH
from psychiatry, social work, psychology and nursing and it was open ORIENTATION PROGRAMME IN PSYCHIATRIC
for the candidates with minimum qualification of graduation or those REHABILITATION SERVICES
who have substantial work experience in the field of rehabilitation.
The programme which is planned to be conducted every year, intends
to train the participants in assessing needs and providing psychiatric
rehabilitation services to the mentally ill, mentally challenged and their
care givers. The syllabus covers introduction to rehabilitation services,
component of psychiatric rehabilitation, need assessment, challenges
in rehabilitation, short term and long term goals in rehabilitation and
visit to rehabilitation centers .It includes both theoretical orientation
and practical exposure to the field.
In the beginning of the programme, a detailed pre assessment
proforma was administered to understand the knowledge, needs and
concerns of the participants a review of the need assessment has
helped as to structure the scheme and contents of the programme.
As the participants belonged to diverse backgrounds and with varying
work experience they were involved in all the clinical activities of the
unit along with academic programmes and lectures from the resource
persons of multi displinary team in rehabilitation. In addition to this
the trainees were allotted clinical cases which they have to work out
throughout the month in consultation with concerned consultants. The
cases were given to them so that they could understand the process,
challenges involved in the rehabilitation of the mentally ill. The trainees
190 PSYCHIATRIC REHABILITATION PSYCHIATRIC REHABILITATION 191
 PSYCHIATRIC
REHABILITATION

2013

National Institute of Mental Health

and Neuro Sciences
Benguluru- 560 029
PSYCHIATRIC REHABILITATION FOREWORD
......................................................
.........................................................................
The magnitude of mental health problems in our society makes it
necessary to organize short term training programmes to address the
shortage of mental health human resources in the country. The
comprehensive mental health care includes not only treating the
symptomatic phase of illness but also developing rehabilitation plans
for the integration of people with psychiatric illness in the community
and involve in livelihood activities. The rehabilitation is a growing
carrier path, in the current global scenario of India being a signatory
of UNCRPD, there is an urgent need for developing and initiating
psychiatric rehabilitation prorgamme for enhancing the quality of life
of the individual and also lead life with dignity. The long-felt needs of
the professionals have been addressed by developing a one-month
Copyright © 2013 training on psychiatric rehabilitation. This hand book is a pioneering
Department of Psychiatry
NIMHANS, Bangalore - 560 029 effort to fill the gap of shortage of mental health professionals.

Price : Rs. ............... The authors have converted their rich clinical experiences into
different training modules and offered one-month course for the
professional working in the area of rehabilitation. They have captured
the best practices, recorded and developed as training modules, and
presented in the thirteen chapters. The authors have made an effort
to develop indigenous literature related to rehabilitation of people with
Printed at :
psychiatric illness. I would like to congratulate the editors and authors
Navarathna Printers,
# 35, 3rd Cross, Sudhamanagar, on their efforts. This hand book would go long way in sensitizing and
Bangalore - 560 027
Phone : 2222 3538 Fax : 4149 5048 motivating the professionals to initiate rehabilitation activities not only
e-mail : navarathnaprinter@[Link] in cities but also at the district and block levels.
 I hope this hand book will prove to be a useful resource and PREFACE
ready reckoner for the mental health professionals and other stake The field of psychiatric rehabilitation has been witnessing a variety
holders to learn about psychiatric rehabilitation. I appreciate the efforts of changes and developments with the concerted efforts of
of Dr [Link] in taking the initiative to compile this book, which psychiatrists, psychiatric social workers, clinical psychologists,
in turn would help the mental health professionals to develop and psychiatric nurses, occupational therapists. There is a sea change in
approaches, methods and techniques which have been used with the
design rehabilitation plan for people with mental illness.
person with psychiatric disabilities, family members, community
Dr. Satish Chandra
agencies for achieving the goal of re-integration of the clients into
Director and Vice Chancellor
active family and community life.
NIMHANS , Bangalore
Institutional, semi-institutional and non-institutional services are
being organized for effective psychiatric rehabilitation with special
focus on cognitive skills, social skills and vocational skills of patients.
Family involvement for the purpose of rehabilitation is intensified.
Potentials of rehabilitation in the individual, family and community
are intensively explored and utilized. In the process of rehabilitation,
attempts are made to coordinate the services of voluntary agencies
and governmental agencies in relation to health (mental health in
particular), welfare, education and development sector. Considering
the ill impacts of stigma attached to mental illness, psychiatric
rehabilitation professionals organize appropriate psycho-education
programmes for the patients, family members as well as civic agencies
in the community. The mental health professionals make sincere
efforts in creating positive awareness in the community about mental
health problems. They try their best to convince the family and
community about the effectiveness of such clinical and rehabilitation
services. In doing so the family and community members are actively
involved in planning, organizing, monitoring and evaluating rehabilitation
services at the institutional and community levels.
 These developments need to reach the people working in the I thank all the vocational instructors at Psychiatric Rehabilitation
field of rehabilitation. For this purpose, a one month training programme Services for their technical support. I am also thankful for the Nursing
was organized in relation to psychiatric rehabilitation services in August staff of psychiatric rehabilitation services for imparting their rich
2012. A total of 16 people participated in the programme. The teaching experiences in the field of psychiatric rehabilitation
materials prepared by the resource persons are compiled and
Finally I would also like to thank the Publication Department of
presented in the form of handbook. This book will be useful to all the
NIMHANS for editorial assistance and Navaratna printers for
professionals and non-professionals working in the area of psychiatric
designing and prining this handbook.
rehabilitation in rural and urban areas.
Last but not the least, I would like to express my appreciation for
I am extremely thankful to our Director and Vice Chancellor of
NIMHANS for his overall encouragement and motivation to take up the trainees for their active involvement in the learning process.
such training programmes. I thank Dr. S.K. Chaturvedi, Professor of [Link]
Psychiatry and Head Psychiatric Rehabilitation Services for his
Innovative ideas, support and guidance. Dr. Jagadisha Thirthalli,
Additional Professor of Psychiatry and Consultant Psychiatric
Rehabilitation Services for his whole hearted co-operation, Dr. R
Parthasarathy , Professor and Former Head of Department of
Psychiatric Social Work for timely support and appropriate guidance
for conducting this programme. I thank my colleagues at Psychiatric
Rehabilitation Services Dr. Naveen Kumar, Dr. Geetha Desai, Dr.
Sivakumar T, Dr. Poornima Bhola, Dr. Aarti Taksal, Dr. Sailaxmi
Gandhi, Dr. N. Janardhana, Mrs. Usha Kiran K T, Dr. Avinash
Waghmare, Ms. Fazeela Jaleel, Ms. Fatema Khanam, Dr. Praveen
for being contributors and resource persons for the training
programme.

My wholehearted thanks to the Heads of the Departments of

Psychiatric Social Work, Psychiatry, and Nursing for their inputs. I
acknowledge the support of Dr. B. N. Gangadhar, Professor of
Psychiatry for arranging the yoga orientation to the participants.
 LIST OF CONTRIBUTORS Dr. Aarti Taksal, PhD, Department of Clinical Psychology,
NIMHANS
Dr. Santosh Kumar Chaturvedi, Professor of Psychiatry and
Head of Psychiatric Rehabilitation Services I/C Department of Ms. Fatema Khanam , Clinical Psychologist, Department of
Psychiatry, NIMHANS Clinical Psychology, NIMHANS

Dr. Jagadisha Thirthalli, Additional Professor, Department Dr. Sailaxmi Gandhi, Assistant Professor, Department of
of Psychiatry, NIMHANS Nursing, NIMHANS

Dr. Geetha Desai, Associate Professor, Department of Late Mr. Naidu D.M, Programme Manager, Basic Needs
Psychiatry, NIMHANS India, Bangalore

Dr. Naveen Kumar C, Assistant professor, Department of

Psychiatry, NIMHANS
Dr. Sivakumar. T, Assistant Professor, Department of
Psychiatric and Neurological Rehabilitation, (Psychiatric
Rehabilitation Services) NIMHANS
Dr. Avinash Waghmare, Senior Resident, Department of
Psychiatric Rehabilitation Services NIMHANS
Dr. Praveen Venkatachalam, Non-PG Junior Resident,
Department of Psychiatric Rehabilitation Services NIMHANS
Dr. B.P Nirmala, Associate Professor, Department of
Psychiatric Social Work, NIMHANS
Dr. Janardhana. N, Assistant Professor, Department of
Psychiatric Social Work, NIMHANS
Mrs. Usha Kiran. K.T, Junior Research Fellow (DST funded
Project on ASD) Department of Child and Adolescent Psychiatry,
NIMHANS
Ms. Faseela Jaleel, PhD Scholar, Department of Psychiatric
Social Work, NIMHANS
Dr. Poornima Bhola, Associate Professor, Department of
Clinical Psychology, NIMHANS
 CONTENTS Chapter 9 :
Cognitive Function Assessment in Rehabilitation
Foreword I
Setting
Preface II
Contributors IV Dr. Poornima Bhola

Chapter 1: Chapter 10 :
Psychiatric Rehabilitation-An Introduction 1 Social Skills: Assessment and Intervention
Dr. Santosh Kumar Chaturvedi in Recovery Orientation Services
Chapter 2 : Dr. Aarti Taksal, Fatema Khanam
Understanding the concept of Disability and Dr. Poornima Bhola
Dr. Naveen Kumar C
Chapter 11 :
Chapter 3 : Vocational Rehabilitation of Persons with
International Perspectives on Rehabilitation Psychiatric Disability
Dr. Praveen Venkatachalam, Dr. Avinash Waghmare
Faseela Jaleel and Dr. B.P Nirmala
and Dr. Geetha Desai
Chapter 4 : Chapter 12 :
Care and Services in Psychiatric Rehabilitation Psychiatric Rehabilitation Services
Dr. B.P Nirmala, Usha Kiran K.T and Faseela Jaleel - A Nursing Orientation
Dr. Sailaxmi Gandhi
Chapter 5 :
Psychoeducation and Education Material Chapter 13 :
on selected Psychiatric illnesses Community Based Rehabilitation for people
Dr. Avinash Waghmare and Dr. Jagadisha Thirthalli with mental illness: Field experiences of
mental health and development programme
Chapter 6 :
in India
Issues Related to Treatment and Management
Dr. Janardhana. N. Naidu, Naidu D.M and
in Psychiatric Rehabilitation Services
Dr. B.P Nirmala
Dr. Sailaxmi Gandhi
Report of the one month training programme on Psychiatric
Chapter 7 : Rehabilitation
Legislation governing people with mental illness
Services held in the month of August 2012 and candidates’ details
Dr. Sivakumar .T, Dr. B.P Nirmala and Usha Kiran K.T
Chapter 8 :
Family Involvement in Psychiatric Rehabilitation
Dr.B.P Nirmala and Faseela Jaleel