Psychosocial rehabilitation

Nurs Clin N Am 38 (2003) 151 160 Psychosocial rehabilitation Deborah Antai-Otong, MS, RN, CNS, NP, CS, FAAN Employee Support Program, Mental Health Outpatient Clinic, VA North Texas Health Care System, 4500 South Lancaster Road, Dallas, TX 75216 Psychosocial rehabilitation is a model that provides a holistic, comprehensive, and seamless plan of care for patients with severe and persistent mental illnesses. Major components of psychosocial rehabilitation include interventions that facilitate symptom management, facilitate social skills training, and improve cognitive performance. The goal of psychosocial rehabilitation has evolved from medication compliance and reduced hospitalization to helping the patient attain independence, employment, meaningful interpersonal relationships, and an improved quality of life [1]. Ultimately, these goals facilitate the highest level of functioning in all spheres, self-efficacy, and well-being for patients with severe and persistent mental disorders. By attaining these goals, patients with schizophrenia and other severe and persistent mental disorders can experience minimal interference from symptoms and neurocognitive deficits. Predictably the success of these programs is enhanced by involvement of families and significant others [2 4]. Achieving these goals requires integration by the interdisciplinary team model that involves the delivery of comprehensive, coordinated, and seamless services that are consumer-friendly and accessible to the patient, caregivers, and cultural and social context. Psychiatric nurses play pivotal roles in the efficacy of evidence-based psychosocial rehabilitation and are important members of interdisciplinary teams that provide holistic health care services ranging from symptom management to facilitating vocational rehabilitation. Psychiatric nurses, similar to other team members, patients, and caregivers, are also responsible for the planning and implementation of these services. This article focuses on psychosocial rehabilitation as an evidence-based practice model for the treatment of schizophrenia and other severe and persistent mental disorders. The role of the psychiatric nurse in the planning and implementation of interdisciplinary interventions that promote symptom management, E-mail address: Deborah.antai-otong@med.va.gov 0029-6465/03/$ - see front matter Ó 2003, Elsevier Science (USA). All rights reserved. doi:10.1016/s0029-6465(02)00068-3

152 D. Antai-Otong / Nurs Clin N Am 38 (2003) 151 160 self-efficacy, assertive community treatment, psychoeducation, and vocational rehabilitation also is discussed. Major components of psychosocial rehabilitation Studies underscore the significance of symptom management, social skills building, and strengthening cognitive functioning to prepare patients for rehabilitation services [3,4]. Pharmacologic interventions are necessary to reduce or extinguish symptoms and provide opportunities for the patient to develop and attain social and mental health rehabilitation and an optimal level of functioning. Psychiatric nurses are responsible for understanding the basis of medication, monitoring for desired responses and acute and chronic adverse drug reactions, and psychoeducation concerning mental illness and treatment options. Regardless of the patient s condition, it is imperative for the nurse to identify symptoms and treatment options and to integrate the patient s individual and cultural needs into treatment planning. Symptom management The initial phase of psychosocial rehabilitation begins during the acute phase, at which time the primary goal is controlling and stabilizing symptoms of severe mental disorders, often with pharmacologic interventions. Depending on the nature of the symptoms, various medications are used. The mainstay treatment of serious and chronic mental illness is pharmacotherapy [5,6]. Predictably the patient s presenting symptoms determine the exact medication. As previously mentioned, antipsychotic or neuroleptic agents are the primary medications of acute and chronic psychosis. Novel neuroleptic agents have been shown to have clinical efficacy in the treatment of treatment-resistant psychosis, although they have doserelated side effects similar to conventional agents with the exception of clozapine. Antidepressants and anxiolytic or antianxiety medications are primary medications for depressive and anxiety symptoms. Although novel antipsychotic agents are preferred for maintenance treatment of psychotic disorders, conventional agents are likely to be used to manage acute symptoms, particularly when a parenteral route is necessary. (See also the Antai-Otong and Jensen articles in this issue concerning nursing implications for the management of acute psychosis and neuroleptic-induced side effects.) Because of notable advantages of novel pharmacologic agents, patients with serious and chronic mental illnesses are more likely to reach an optimal level of function when this approach is integrated with psychosocial interventions. Of particular importance to medication management is family and patient psychoeducation. Patients with schizophrenia may enter treatment with acute psychosis. Efforts to assess the underlying cause of the acute symptoms must involve making a differential diagnosis. Nurses

D. Antai-Otong / Nurs Clin N Am 38 (2003) 151 160 153 often are involved and gather crucial data, including assessing vital signs, drug toxicology screens, and chemistry profiles; performing a mental status examination; and obtaining an extensive substance abuse history that provides information about symptoms, duration, past treatment, and current medication. Cultural considerations must be an integral aspect of the assessment process to reduce misdiagnosis and ultimately inappropriate treatment planning. Cultural considerations also must include family involvement, patient preferences, and the role of religion and other spiritual components [7,8]. When a definitive diagnosis is established, treatment of acute psychosis involves parenteral or oral administration of a neuroleptic, such as haloperidol (Haldol), and a benzodiazepine, such as lorazepam (Ativan). Another example is acute mania in a patient with a history of bipolar I disorder. Treatment is often similar for these two patients. In contrast, a patient experiencing acute anxiety may complain of chest pain, difficulty breathing, and odd physical sensations and require a dose of a benzodiazepine to reduce anxiety. Regardless of the presentation, these patients require immediate attention and psychotherapeutic and pharmacologic interventions to move from the acute phase to rehabilitation. Acute management of the patient s symptoms may involve acute and short-term hospitalization to stabilize medical and psychiatric symptoms or referral to a day hospital program or individual psychotherapist. Of particular importance to the nurse during this phase is making an accurate diagnosis and initiating appropriate interventions and referrals. Community referrals must involve family therapy and involvement and a comprehensive, seamless plan of care. The efficacy of these interventions is well documented and shows that they are cost-effective and provide quality mental health care that prevents psychotic relapses and rehospitalization [2,9 11]. Self-efficacy and management of illness As patients transition from the acute symptom management stage, psychiatric nurses must monitor their response to treatment and provide opportunities for success. As the nurse administers or prescribes neuroleptic agents, it is imperative to educate the patient and significant others about schizophrenia or other serious mental disorders, reasons for medications, and potential side effects. This process facilitates insight into the patient s symptoms and illness and promotes self-efficacy as the patient moves through the treatment continuum. Understandably, psychiatric rehabilitation evolves during the acute stages of a psychiatric disorder and continues throughout the life span. Mental health services must parallel stages of symptoms across the treatment continuum and meet the patient s holistic needs and foster competence and management of illness. Self-management of illness often requires structured interventions that promote self-efficacy, independence, employment, quality interpersonal relationships, and a good quality of life. Self-efficacy and management of

154 D. Antai-Otong / Nurs Clin N Am 38 (2003) 151 160 symptoms are crucial to moving from inpatient to community-based settings. Throughout the course of treatment, patient and family needs must be assessed thoroughly so that they can guide treatment planning and facilitate competence in managing symptoms and responsibility for treatment outcomes. Dhillon and Dollieslager [3] delineated five core objectives of psychosocial rehabilitation as follows: Assess the patient s personal goals in life, including self-efficacy, autonomy, and quality of time with friends and family, and how they can be facilitated by inpatient modalities and symptom stabilization Provide health education to the patient and significant others concerning the nature of the mental illness and how medications may be useful in restoring self-control Educate the patient about medication and treatment adverse effects and the importance of self-monitoring and collaborating with the nurse or other health care provider concerning medication and its effect Embrace the patient s cultural needs and collaborate with the family or other community-based resources Engage the patient in decision making regarding appropriate aftercare plans for residential and treatment needs after discharge An avenue that integrates these principles is intensive case management. Psychotherapeutic interventions Intensive case management Historically, case management did not meet the needs of patients with schizophrenia because patients were referred to a single case manager who functioned as a broker of services, rather than being assigned to a community treatment team. Case management refers to the coordination, integration, and allocation of holistic care within a spectrum of resources. This concept has evolved over the years in an effort to overcome deficiencies in community-based mental health care and correct fragmented care and lack of continuity of care. The traditional case management model was unsuccessful in reducing hospitalization with little evidence of improving mental health social functioning or quality of life. This older model had high caseloads and used an individual versus a team approach to access patient resources, emphasizing community team outreach rather than referring the patient to other providers. This may have been related to the model s failure to reflect the relevance of cognitive and social skills necessary to follow-up with appointments and get one s needs met. Combined, these factors placed the patient at risk of relapse. A contemporary approach to intensive case management is the assertive community treatment (ACT) program [3]. With this approach, the patient

D. Antai-Otong / Nurs Clin N Am 38 (2003) 151 160 155 is assigned to an interdisciplinary community team that includes a case manager, nurse, and other providers. ACT team members have lower caseloads than their predecessors. There is high staff-to-patient ratio that delivers services when and where needed by the patient, 24 hours a day, 7 days a week [12 15]. The primary goal of intensive case management is prevention of rehospitalization. Reducing rehospitalization in high-risk patients through the provision of comprehensive integrated community services is cost-effective and a necessary component of this approach. Most researchers looking for cost-effective mental health services for the seriously mentally ill have found that the ACT model program consistently shows reduced hospitalization and stability in the community and housing [2,6,11,14]. The case manager role in the ACT program is especially suitable for the nurse because nurses traditionally have been health care brokers, providers of mental health care, and active members of the interdisciplinary team. Ideally, as a case manager, the nurse oversees and integrates seamless holistic treatment planning and facilitates patient access to appropriate community services [11,16]. An integral aspect of an intensive case management program is social skills training and vocational rehabilitation. Implementation of these components further strengthens rehabilitation, promotes recovery, and a higher level of functioning. Social skills training and rehabilitation Intensive case management programs such as ACT offer a wealth of opportunities to provide effective and individualized mental health services to patients with serious mental illness. Another aspect of integrated services using this model is social skills training. Psychiatric nurses involved in social skills training must do a comprehensive biopsychosocial assessment and determine the patient s mental and physical health and readiness for training and rehabilitation. The patient s social and functional status often parallels symptom management and cognition [14]. Studies show that cognitive capabilities and community functioning are strongly related. Medications, specifically novel antipsychotics or neuroleptics, seem to be the mediator between social functioning and cognitive performance [17,18]. Social skills training refers to necessary competencies that allow for optimal social performance. Social skills training employs learning theory principles to facilitate optimal social and community functioning, including activities of daily living, employment, leisure, and interpersonal relationships. The premise of social skills training is that it affords the patient opportunities to reach an optimal level of functioning and self-efficacy and reduce relapse. Bellack and Mueser [19] described the following models of social skills training: basic, social problem solving, and cognitive remediation. The basic model involves corrective learning, practiced through various means,

156 D. Antai-Otong / Nurs Clin N Am 38 (2003) 151 160 including role playing. If the patient lacks assertive communication skills, the nurse can teach these skills and enhance them through role playing and constructive feedback. The social problem-solving model focuses on enhancing impairments in information processing assumed to result in social skills impairments. Major foci for the social problem-solving model include requiring changes in medication and symptom management, leisure, communication skills, and self-care. Each domain is taught in a module format with the goal of correcting receptive, processing, and transmitting skills deficits. Nursing interventions that promote these changes include providing examples of potential situations and asking the patient to think of with possible solutions. When these solutions are presented, the nurse can offer feedback and options for improving communication and problemsolving skills. These solutions also may include side effects and possible ways to resolve them, including whether to call the provider concerning their effects. The premise underlying the cognitive remediation model includes cognitive deficits in attention or planning and helping the patient move from an individual approach to a community approach [20]. Nursing interventions involving cognitive remediation may include asking questions about upcoming situations regarding employment, conflict management, or need for medication changes. By offering these scenarios and providing basic communications tools to resolve them, the nurse enhances the patient s problem-solving, stress-management, and conflict-resolution skills, resulting in higher confidence and self-esteem. Psychoeducation and family therapy The global burden of serious mental illnesses, such as schizophrenia, is profound and often extends to the family, culture, and community. Efforts to strengthen family and community-based resources are crucial to successful reintegration into the community and prevention of rehospitalization. The ACT program has been mentioned as one aspect of this process. Another aspect of the ACT program requires family or significant other involvement. Because of the intimate role that nurses play in mental health treatment planning, they must play key roles in identifying family, patient, cultural, and community stressors and strengths and collaborate with other members of the treatment team to support and empower family coping skills. Family stress often manifests as expressed emotion or an index of criticism, overinvolvement, and hostility. The expressed emotion research shows that when levels of emotion are reduced, so are psychotic relapses [17]. Research consistently shows that the vulnerability-stress model of schizophrenia suggests that patients with mental illnesses are likely to relapse and return to the hospital when community resources are inadequate [21]. Because schizophrenia and other severe and persistent mental disorders are costly and labor intensive, efforts to strengthen the family and

D. Antai-Otong / Nurs Clin N Am 38 (2003) 151 160 157 community resources during these times are crucial to the mental health of the patient and community. Multifamily groups enable members to express their feelings and concerns about living with someone with a chronic mental disorder and promote self-management of illness. Nursing implications from this premise include assessing family stressors, identifying family strengths, and providing health education that enables family members to understand their loved one s symptoms and ways to manage them and to facilitate health coping skills. Working with other team members and community agencies provides numerous opportunities for the patient and family to strengthen their coping skills and develop successful treatment recovery and outcome. Psychiatric nurses must work with the patient and family and formulate and implement a comprehensive intervention program that eventually includes reducing dosages of antipsychotic medication, relying on novel medications to control symptoms, and implementing psychosocial interventions that integrate specific needs of the patient and family. There are many psychosocial family interventions, including those that begin on inpatient units and continue on an outpatient basis. One program has been established for first-episode psychosis and has a 1-year, phasespecific, community-oriented treatment mode [22]. Researchers using this model submit that poor outcomes are linked to delayed treatment, lack of integration, and lack of medical and psychosocial interventions [22,23]. Support for this new approach that involves early interventions, particularly for first-episode schizophrenia, is showing great promise because it provides treatment on a continuum that begins during the acute period and continues into the community [22,23]. Major goals of this model include bolstering the patient s activities of daily living skills, improving communication skills, and providing mutual support during the transitional phase of recovery from acute psychosis. This program is based on a structured 8-week model that reflects various themes, including self-identity, health education concerning the definition of psychosis, peer pressure and substance-related disorders, family and social interactions and medications, stigma, social skills and recovery, return to work or school, and warning signs of relapse. When patients complete this introductory phase, cognitive-oriented skills training is introduced and implemented over a 10-week period. As with most models, family intervention is an integral part of this training; this particular model for first-episode psychosis is based on Anderson and colleagues [24] psychoeducation and management teaching model, modified to address the specific needs of younger first-episode patients. A period of engagement, initial crisis resolution, social support, and a series of psychoeducation workshops strengthen the patient and family s coping skills and assist them in managing various stressors associated with having a serious and chronic mental disorder. This psychoeducation model was designed for first-episode psychosis, but major components can be modified to meet the needs of most patients experiencing

158 D. Antai-Otong / Nurs Clin N Am 38 (2003) 151 160 a serious and chronic mental illness. Psychiatric nurses play pivotal roles in working with the patient with serious mental disorders from the acute stage to the transition to family and community-based settings. Throughout the treatment process, patients must be empowered and encouraged to take responsibility for their recovery. Through self-efficacy activities, family involvement, and psychoeducation, the patient gains a sense of independence and confidence to seek and form quality interpersonal relationships, initially with the nurse and later through family interactions. As these skills evolve, so does confidence that propels the patient to participate in workshops and other community employment. Nurses must offer opportunities for the patient and family to identify and express concerns as consumers and promote a good quality of life. Supported employment Ultimately, psychosocial rehabilitation prepares the patient for supported employment [5,26]. These programs offer incentives for patients with severe mental disorders to increase their autonomy as recovery or rehabilitation progresses. Major goals of these programs include assisting individuals with disabilities, such as chronic mental illness, as much as possible in the competitive labor market that parallels their strengths, preferences, priorities, and abilities [25]. In addition to benefiting the patient, supported employment adds to the workforce and community. Nurse case managers also provide opportunities to participate in supportive psychotherapy and problem solving that assist the patient in daily problems and coping with his or her illness. Through structured or supervised workshops and work programs, patients gain a sense of self-worth and independence and develop interpersonal relationships that involve family members and peers. Research studies indicate that a major barrier to supported employment is access despite their increasing use. It is imperative for nurses to stress the importance of self-management and deal with substance-related disorders. As the patient moves through the recovery process and treatment plan continuum, his or her ability to feel confidence and control his or her symptoms often is guided by available resources, absence of substancerelated disorders, and motivation to stay in treatment. Psychosocial rehabilitation is one aspect that fosters successful treatment outcomes, independence, self-management of illness, meaningful relationships, and a good quality of life. Psychiatric nurses play pivotal roles in helping the patient attain these goals. Summary One example of a psychosocial rehabilitation model uses an intensive case management approach. This approach offers an interdisciplinary model that

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