Psychiatric Rehabilitation

1
Psychiatric Rehabilitation

• Abraham (Rami) Rudnick, MD, PhD, CPRP

2
Course Outline

• Objectives - increase knowledge and skills in
  psychiatric rehabilitation.
• Methods - interactive lectures, guided reading
  and self-learning (e.g., PBL), discussions, field
  application, simulations (e.g., role playing).
• References (partial) -
  
• Anthony et al 2002.
  
• Elitzur 2002.
  
• Israel law for rehabilitation of the
  psychiatrically
• disabled in the community 2000.

3
Course Topics

• A history of psychiatric rehabilitation.
• Principles of psychiatric rehabilitation.
• Environments and programs in psychiatric
  rehabilitation.
• Psychiatric rehabilitation in a vocational
  context.
• Psychiatric rehabilitation process.
• Cognitive rehabilitation.
• Social skills training.
• Facilitating activities of daily living.
• Psychoeducation.
• Supportive and self-oriented interventions.
• Family education and cultural adaptation.
• Case management and other environmental
  interventions.
• Ethical problems in psychiatric rehabilitation.

4
A History of Psychiatric Rehabilitation

• Abraham (Rami) Rudnick, MD, PhD, CPRP
• Objectives - increase knowledge of history of
  psychiatric rehabilitation.

5
Psychiatric Revolutions

• Liberation of mental patients (Pinel).
• Legitimation of the unconscious (Freud).
• De-institutionalization (and antipsychotics).
• Atypical antipsychotics (clozapine)? DSM?

6
Psychiatric Rehabilitation Paradigm

• Scientific field.
• Clinical practice.
• Social movement.
• Ideology?

7
The Boston University Center

• Anthony et al.
• Origins - physical rehabilitation, humanistic
  psychology, human resources theory.
• Client-centered operational approach.
• Focus - Psychiatric disability.
• Academic degrees (MA, PhD, post-doc).
• Psychiatric Rehabilitation Journal.
• International development program.

8
The UCLA Center

• Liberman et al.
• Origins - Medical model, learning theory.
• Biobehavioral standardized approach.
• Focus - schizophrenia.
• Module kits.

9
Fountain House, New York

• Ex-patients group (Beard et al).
• Origins - de-institutionalization, self-help.
• Clubhouse approach.
• Focus - all mental illness.
• International clubhouse accreditation.

10
IAPSRS

• International Association of Psychosocial
  Rehabilitation Services.
• Eclectic approach.
• Focus - SPMI (severe and persistent mental
  illness).
• Certification.
• Code of ethics.

11
London Institute of Psychiatry

• Wing, Leff et al.
• Origins - social and community psychiatry,
  epidemiology.
• Psychosocial approach.
• Focus - particularly psychotic disorders.
• Subspecialty - rehabilitation psychiatry.

12
Others

• Matrix (Rutman).
• Thresholds (Dincin).
• Chicago University Center (Corrigan).
• Dartmouth Center (Drake, Mueser).
• Indiana University (Bond).
• National Empowerment Center (Fisher).
• Philadelphia Association (Laing).
• Bern University (Brenner).
• Also - Bellack, Strauss, Rapp, Deegan and
  more.

13
Psychiatric Rehabilitation in Israel -
past and present

• Past institutionalization.
• Recent and ongoing de-institutionalization.
• 1990s law (and amendments) for treatment of the
  mentally ill.
• 2000 law for rehabilitation of the
  psychiatrically disabled in the community.
• 2003 Mental health care reform - transfer of
  responsibility for mental health care from
  government to HMOs.

14
Psychiatric Rehabilitation in Israel -
future

• Other-age psychiatric rehabilitation
  (adolescent/geriatric)?
• Multi-disability psychiatric rehabilitation (SPMI
  substance abuse/developmental
  disability/physical disability)?
• Forensic psychiatric rehabilitation?
• Culturally-adapted psychiatric rehabilitation?
• Integration/disengagement from treatment?

15
Sources

• Boston University Center for Psychiatric
  Rehabilitation (books, booklets, multi-media
  kits, Psychiatric Rehabilitation Journal,
  e-casts, conferences).
• UCLA and other centers publications.
• IAPSRS publications and conferences.
• General journals - Psychiatric Services,
  Schizophrenia Bulletin, and more.
• Websites - Voices, and more.

16
Principles of Psychiatric
Rehabilitation

• Abraham (Rami) Rudnick, MD, PhD, CPRP
• Objectives - increase knowledge and skills
  related to principles of psychiatric
  rehabilitation.

17
Vision of Psychiatric
Rehabilitation (adapted from Anthony et al
2002)

• Recovery.

18
Goals of Psychiatric
Rehabilitation (adapted from Pratt et al
1999)

• Community integration.
• Quality of life
• Optimally independent functioning.

19
Values of Psychiatric
Rehabilitation (Pratt et al 1999)

• Self-determination.
• Dignity and worth of every individual.
• Optimism.
• Capacity of all individuals to learn grow.
• Cultural sensitivity.

20
Guiding principles of
Psychiatric Rehabilitation (Pratt et al
1999)

• Individualization of all services.
• Maximum client involvement, preference, and
  choice.
• Normalized and community-based services.
• Strengths focus.
• Situational assessments.
• Treatment/rehabilitation integration, holistic
  approach.
• Ongoing, accessible, coordinated services.
• Vocational focus.
• Skills training.
• Environmental modifications and supports.
• Partnership with the family.
• Evaluative, assessment, outcome-oriented focus.

21
Principles - Exercise Discussion of
Traditional Claims (Adapted
from Anthony et al 2002)

• Psychiatric diagnosis is a central predictor of
  rehabilitation outcome (e.g., the diagnostic
  label of schizophrenia predicts functional
  deterioration).
• Psychiatric treatment is necessary for successful
  psychiatric rehabilitation.
• Functioning in one type of environment (e.g.,
  residential) is highly predictive of functioning
  in another type of environment (e.g., vocational).

22
Environments and Programs in Psychiatric
Rehabilitation

• Abraham (Rami) Rudnick, MD, PhD, CPRP
• Objectives - increase knowledge and skills
  related to environments and programs in
  psychiatric rehabilitation.

23
Environment - Definition (Anthony et al 2002)

• Environment role setting
• Examples - resident in a group home.
• tenant in a rented
  apartment.
• cashier at supermarket.
• gardeners assistant at
  nursery.
• apprentice mechanic at
  garage.
• student in PSR distance ed
  program.

24
Environments - Classification

• Residential
• Vocational
• Educational
• Social
• Family
• Leisure
• Sexual
• Spiritual
• Healthcare
• Daily living
• Self

25
Success and Satisfaction

• Focus person in relation to their environment.
• Success (functioning) required skills and
  supports.
• Satisfaction (quality of life) desired skills
  and supports.

26
Skills and Supports - Examples

• Physical skills - lifting weights, ironing, etc.
• Emotional skills - asking for help, managing
  anger, etc.
• Cognitive skills - scheduling tasks, assessing
  situations, etc.
• Person supports - case manager, friend, etc.
• Places supports - Laundrymat, quiet lounge, etc.
• Activity supports - lunch break, tutoring
  session, etc.
• Thing supports - bus pass, work boots, etc.

27
Programs - Principles

• Mission (or purpose).
• Specialization (according to environments and
  populations).
• Fidelity (to PSR principles and EB model).
• Structure (operating guidelines, activities,
  documentation).
• Staffing (amount, qualifications, training).
• Accountability.
• Quality improvement.

28
Programs - General Classification

• Independent.
• Supported.
• Sheltered.
• Institutional.
• Combined.
• Transient.
• Long-term.

29
Success and Satisfaction - Exercise

• Identify your work environment.
• Suggest 2 skills required for success.
• Suggest 2 skills desired for satisfaction.
• Suggest 2 supports required for success.
• Suggest 2 supports desired for satisfaction.

30
Programs - Exercise

• Describe your programs mission (or purpose).
• Characterize your programs specialization
  (according to environments and populations).
• Analyze your programs fidelity (to PSR
  principles and EB model).

31
Psychiatric Rehabilitation in a Vocational Context

• Abraham (Rami) Rudnick, MD, PhD, CPRP
• Objectives - increase knowledge and skills
  related to vocational psychiatric rehabilitation.

32
Barriers to Employment (Pratt et al
1999)

• Stigma (societal, professional and self).
• Misguided services.
• Lack of vocational experience.
• Psychiatric disability.
• Possible loss of benefits.
• Legal.

33
Features of Effective Vocational Rehab (Pratt et
al 1999)

• Practitioner (partnership, system-oriented).
• Process (comprehensive, dynamic, adaptable).
• Programs (real work, real pay, community
  settings).
• Principles (client choice, community and clinical
  integration, linkage, natural supports, rapid
  placement, job accommodations, service
  continuity, employer education about needs,
  abilities and contribution of clients).

34
Vocational Rehab Modalities

• Transitional employment.
• Fairweather Lodges (residential vocational).
• Hospital-based work programs.
• Job clubs.
• Sheltered workshops, affirmative industries, and
  client-employing businesses.
• Supported employment (place-train,
  choose-get-keep, individual placement and
  support, job coach, work crew, SE in ACT).
• Vocational Exploration Services (tours,
  volunteering, sampling, shadowing, internships).
• Assessment and pre-vocational services.

35
Occupational Psych Rehab

• Supported education.
• Leisure rehabilitation.
• Spiritual enhancement.

36
Psychiatric Vocational Rehabilitation - Exercise

• Discuss adapting a local vocational
  rehabilitation service to the features of
  effective vocational rehabilitation.

37
Psychiatric Rehabilitation Process

• Abraham (Rami) Rudnick, MD, PhD, CPRP
• Objectives - increase knowledge and skills
  related to psychiatric rehabilitation diagnosis,
  planning, intervention and outcome evaluation.

38
Psychiatric Rehabilitation Diagnosis (Anthony et
al 2002)

• Assessing and developing readiness (need,
  commitment, awareness, relationship).
• Setting an overall rehabilitation goal
  (connecting with clients, identifying personal
  criteria, describing alternative environments,
  choosing the goal).
• Functional assessment (comparing expected and
  actual skills and abilities).
• Resource assessment (comparing expected and
  actual supports and resources).

39
Psychiatric Rehabilitation Planning (adapted from
Anthony et al 2002)

• Client-centered.
• Problem-focused.
• Strength-oriented.
• Periodic.
• Planning for skills and resources development and
  maintenance (setting priorities, defining
  objectives, choosing interventions, formulating
  the plan).

40
Psychiatric Rehabilitation Intervention (Anthony
et al 2002)

• Direct skills teaching (outlining skill content,
  planning the lesson, coaching the client).
• Skills use programming (identifying barriers,
  developing the program, supporting client
  action).
• Resource coordination (marketing clients to
  resources, problem solving, programming resource
  use).
• Resource modification (assessing readiness for
  change, proposing change, consulting to
  resources, training resources)

41
Psychiatric Rehabilitation Outcome Evaluation

• Goal accomplishment.
• Quality of life.
• Functioning.
• Service satisfaction.
• Severity of symptoms and adverse effects.
• General morbidity and mortality.
• Caregiver burden and experience.
• Cost-benefit.

42
Psychiatric Rehabilitation Process - Exercise

• Conduct and document leisure rehabilitation
  diagnosis and planning with a simulated client.

43
Cognitive Rehabilitation

• Abraham (Rami) Rudnick, MD, PhD, CPRP
• Objectives - increase knowledge and skills
  related to cognitive rehabilitation.

44
Mental Disorders with Cognitive
Impairments

• Psychotic disorders (e.g., schizophrenia)
• Cognitive disorders (e.g., dementia)
• Developmental disorders (e.g., autism)
• Affective disorders (e.g., major depression)
• Substance-related disorders (e.g., alcoholism)
• Others (e.g., dissociative amnesia)

45
Impairments in Schizophrenia

• Positive symptoms
  (e.g., delusions,
  hallucinations)
• Negative symptoms
  (e.g., poverty of speech, flat
  affect)
• Non-specific symptoms
  (e.g., depression, anxiety)
• Cognitive impairments
  (e.g., memory deficits, leading
  to functional deficits)

46
Cognitive Functions

• Intelligence
• Attention (initiation, span, shift, split)
• Memory (LTM, STM, working memory, semantic
  memory, episodic memory, procedural memory, and
  other types)
• Language (production, perception and repetition
  of speech, writing, reading, and prosody)
• Visuomotor function
• Perception and gnosis
• Praxis
• Executive function (planning, categorizing,
  organizing)
• Meta-representation and other functions

47
Cognitive Impairments in Schizophrenia(Calev
1999)

• Intelligence - intellectual deterioration?
  (inconclusive)
• Attention - filtering and categorizing
  impairments
• Memory - Anterograde amnesia, working memory
  deficit, global memory imapirment (secondary to
  attention deficits and executive dysfunction?)
• Language - non-localized findings
• Visuomotor - poor coordination
• Perception and gnosis - hallucinations and
  delusions?
• Executive function - task hypofrontality, e.g.,
  on WCST (secondary to temporal lobe dysfunction?)
• Hemispheric function - left overactivation?
  (inconclusive evidence)
• Secondary to background and environment?

48
Cognitive Rehabilitation

• Origins in cognitive rehabilitation of brain
  injury - restorative (treatment) and compensatory
  (rehabilitative and support) approaches (Sohlberg
  and Mateer 1989) assessment tools
• Classification of cognitive rehab (Diller 1987)
  
• a. Deficiency models (treatment by
  correction/reduction of deficits)
  b.
  Interference models (rehabilitation by
  enhancement of alternative skills)
  c.
  Absence models (support by environment aids)
• Application to mental illnesses (1990s) - mixed
  models most success with client-centered
  compensatory approaches (Bellack) some success
  with restorative approaches (Spaulding)

49
Cognitive Rehabilitation in Schizophrenia

• Testing - screeing (MMSE, clock drawing),
  neuropsych batteries.
• Medications - e.g., clozapine may improve
  attention, but may disrupt executive function and
  visual memory (Goldberg et al) reduce adverse
  effects, such as sedation.
• Integrated psychological therapy (Brenner et al
  1992) - first addresses basic cognitive deficits
  and then addresses related social skills
  deficits as effective in improving executive
  functioning as behavioral social skills training
  (Spaulding 1994)
• Attention process training (Jaeger et al 1999) -
  expand attention capacity by repeated exposure
  (not generalizable?)
• Prospective memory training (Jaeger et al 1999) -
  individualized cognitive aids, e.g., notebook,
  environmental cues poor evidence.
• Non-cognitive rehabilitation interventions -
  e.g., vocational individual placement and support
  (Becker Drake 1994)

50
Case Report

• ID 32y single long-term inpatient male.
• Dx Schizophrenia, with resistant psychosis and
  disorganized behavior Hx of medication-induced
  prolonged seizure.
• Rp Clozapine 600 mg daily.
• Functional deficits of relevance ADLs, social
  skills.
• Cognitive impairments of relevance STM,
  executive function.
• Cognitive rehabilitation Compensatory (absence
  model).

51
Cognitive Rehabilitation - Exercise

• Design compensatory cognitive interventions for
  STM impairment-induced ADL difficulties of person
  reported above.

52
Social Skills Training

• Abraham (Rami) Rudnick, MD, PhD, CPRP
• Objectives - increase knowledge and skills
  related to social skills training.

53
Social Cognition (Newman 2001)

• Cognitive processes underlying social behavior.
• How the actual or imagined presence of other
  people affects cognitive processes.
• Coordinated cognitive activity in dyads or
  groups.
• The species-general psychological mechanisms that
  evolved to solve the adaptive problems presented
  by group living.

54
Social Cognition in Schizophrenia (Penn and
Corrigan 2001)

• Deficit models - Impaired perception of
  (negative) emotions or of abstract features and
  cues in social situations, lack of social
  knowledge or of theory of mind, general
  neurocognitive impairments.
• Bias models - externalizing bias (blaming others
  for negative outcomes), self-serving bias (taking
  credit for success and denying responsibility for
  failure).
• Relation of social cognition to social
  functioning.

55
Social Functioning in Schizophrenia (Brekke et al
2002)

• Social competence.
• Quality of relations.
• Satisfaction.
• Symmetry of relationships.
• Number of close friends.

56
Social Skills Training (Wallace 1982)

• Goal - teaching patients socially-skilled problem
  solving in instrumental and friendship/dating
  situations.
• Objectives - Improvement of receiving skills
  (identifying others signs and goals), processing
  skills (evaluation of impact of alternatives on
  others and on goals) and sending skills (body
  language, active listening, asserting oneself,
  etc).
• Methods - group training, role playing, graded
  exposure, feedback.
• Results - Not effective? (Pilling et al 2002).

57
Social Skills Training - Exercise

• Practice communication skills
  (Baile and Buckman 1998)
  1. Body language and active listening.
  2. Open questions and empathic responses.

58
Facilitating Activities of Daily Living

• Abraham (Rami) Rudnick, MD, PhD, CPRP
• Objectives - increase knowledge and skills
  related to activities of daily living
  (self-care).

59
Uniform Terminology (AOTA 1994)

• Performance areas - Activities of daily living,
  work and productive activities, play or leisure
  activities.
• Performance components - sensorimotor, cognitive,
  psychosocial.
• Performance contexts - temporal, environmental.

60
Activities of Daily Living (ADL) - Routine Task
Inventory (Allen 1985)

• Primary/physical ADL - grooming, dressing,
  bathing, walking, feeding, toileting.
• Secondary/instrumental (I)ADL - housekeeping,
  preparing food, spending money, taking
  medication, doing laundry, traveling, shopping,
  telephoning.

61
ADLs and SPMI (Bonder 1995)

• Schizophrenia - dysfunction related to illness
  severity, phase and type (e.g., correlated with
  negative and cognitive symptoms) also related to
  person and environment variables.
• Major depression - dysfunction related to anergy,
  anhedonia, loss of appetite, psychomotor
  abnormality, self-esteem generally lack of
  motivation rather than skills.
• Anxiety disorders - Mostly avoidance-induced
  dysfunction of IADL (also ADL dysfunction in
  severe PTSD and OCD).

62
Facilitating ADL and Other Activities (Bonder
1995)

• Enhance skills and performance - provide
  teaching, practice, reinforcement, reality
  orientation, sensory stimulation.
• Improve self-image and self expression - provide
  activities with high probability of success,
  feedback, art activities.
• Modify environment to maximize function -
  structure environment, increase sign/noise ratio,
  facilitate supports.

63
Facilitating ADL - Exercise

• Evaluate relevant ADL of a person with SPMI
  according to Routine Task Inventory (Allen 1985).
• Suggest ways of facilitating relevant ADL of that
  person.

64
Psychoeducation

• Abraham (Rami) Rudnick, MD, PhD, CPRP
• Objectives - increase knowledge and skills
  related to psychoeducation.

65
Definitions (Mueser et al 2002)

• Illness management - professional-based
  interventions designed to help people collaborate
  (actively) with professionals in the treatment of
  their mental illness, reduce their susceptibility
  to relapses, and cope more effectively with their
  symptoms (evidence-based).
• Illness self-management - peer-facilitated
  services aimed at helping people cope more
  effectively with their mental illness and
  facilitating peoples ability to take care of
  themselves (not evidence-based).

66
Types of Illness Management (Mueser et al 2002)

• Broad-based psychoeducation programs (provide
  information) - increased knowledge of mental
  illness and of medications.
• Medication-focused programs (cognitive-behavioral
  behavioral tailoring, simplifying medication
  regimen, motivational interviewing, and social
  skills training) - increased adherence to
  treatment.
• Relapse prevention (recognize triggers and early
  warning signs and prevent exacerbation) -
  decreased relapse and rehospitalization.

67
Types of Illness Management (cont)

• Coping skills training (deal with symptoms and
  stress) - decreased symptom severity.
• Comprehensive programs (e.g., including problem
  solving) - varied improved outcomes.
• Cognitive-behavioral treatment of psychotic
  symptoms (teaching coping skills and modifying
  dysfunctional beliefs) - decreased positive (and
  negative?) symptom severity.

68
Implementation and Dissemination (Mueser et al
2002)

• Evidence-base.
• Manual use.
• Policies and standards.
• Funding.
• Endorsement across programs and services.
• Ongoing or repeated use.
• Fail-safe participation.
• Family involvement.

69
Managing Warning Signs - Exercise (Adapted from
Liberman et al)

• Role play discussion of patient with therapist
  (using feedback, modeling, prompting, shaping,
  overcoming resistance)
• 1. Identification of warning signs
• (vegetative, emotional, cognitive,
  behavioral).
• 2. Differentiation from persistent
• symptoms, medication adverse effects
• and variations in mood.
• 3. Suggestion of coping and emergency plan.

70
Supportive and Self-Oriented Interventions

• Abraham (Rami) Rudnick, MD, PhD, CPRP
• Objectives - increase knowledge and skills
  related to supportive and self-oriented
  interventions.

71
Supportive Psychotherapy

• Goals - e.g., improved adaptation via
  strengthening of ego or decreasing stress on ego
  from id, super-ego and reality (Rockland 1989,
  1994).
• Psychodynamic psychotherapy as varied - drive
  theory, ego psychology, object relations theory,
  self psychology (McWilliams 1994).
• Supportive psychotherapy as alternative to
  exploratory psychotherapy, which is not
  successful in SPMI (Stanton/Gunderson 1984).
• Supportive psychotherapy as directive,
  reality-oriented, controlled therapist exposure,
  focus on conscious and preconscious material.

72
Supportive Psychotherapy (cont)

• Stabilization - building therapeutic alliance,
  psychoeducation (also for family if needed),
  negotiated psychopharmacological regimen.
• Maintenance - undermining maladaptive and
  supporting adaptive defenses, handling alliance,
  transference, countertransference, resistance,
  working through, attenuation (rather than
  termination).

73
Self-Oriented Aspects in Psychiatric
Rehabilitation

• Self aspects are impacted by psychiatric
  disability (e.g, self-labeling, self-esteem,
  self-confidence, self-efficacy).
• Self aspects are central to psychiatric
  rehabilitation (to satisfaction and to success,
  as well as to choice of environments).
• Recovery processes involve change in self aspects
  (Anthony et al 2002).

74
Self-Oriented Interventions in Psychiatric
Rehabilitation

• Readiness assessment and modification.
• Recovery facilitation.
• Future interventions - interaction between person
  and illness (Roe et al)?

75
Supportive Psychotherapy -Exercise

• A., a 45 year-old married woman with
  schizophrenia has been fired, as part of mass
  firing, from her 2 year-old job as a clerk. She
  becomes depressed and aims to sue the workplace
  due to what she thinks is personal persecution.
• Suggest interventions for ego strengthening and
  decreasing stress on ego (from id, super-ego and
  reality).

76
Family Education and Cultural Adaptation

• Abraham (Rami) Rudnick, MD, PhD, CPRP
• Objectives - increase knowledge and skills
  related to family education and cultural
  adaptation in psychiatric rehabilitation.

77
Family Issues in Mental Illness

• Family as primary caregiver and partner.
• Impact of family on mentally ill person
  etiological myth, expressed emotion/family
  climate, independence/dependence/interdependence,
  functional expectancy.
• Impact of mentally ill person on family
  objective and subjective burden, resilience,
  level of involvement, stages of family
  recovery - 1.
  discovery/denial, 2. recognition/acceptance,
  3. coping/competence, 4.
  personal/political advocacy (Spaniol et al 1994).

78
Family Interventions in Psychiatric Rehabilitation

• Components - psychoeducation, behavioral problem
  solving, support, and crisis management training
  (Lehman et al 1998).
• Timeframe - about 1 year or more.
• Format - multi-family with participation of
  mentally ill persons?
• Outcomes - improved relapse, functioning, burden,
  cost (Leff, Hogarty, Falloon, McFarlane, others).
• Complementary Approaches - self-help (e.g.,
  NAMI), long-term planning (Hatfield).

79
Cultural Variance in Psychiatric
Rehabilitation

• Values (e.g., individualism vs. collectivism).
• Goals (e.g., self-growth vs. falling in line).
• Beliefs (e.g., secular vs. religious health
  beliefs).
• Behaviors (e.g., fringe vs. conservative
  clothing).
• Environments (profitable vs. respectable work).
• Skills (e.g., native vs. second language).
• Supports (e.g., extended vs. nuclear family).
• Symptoms (e.g., cognitive vs. somatic depression).

80
Cultural Sensitivity in Psychiatric
Rehabilitation

• Cultural awareness.
• Multi-cultural tolerance.
• Professional translation and cultural mediation
  as needed.
• Cross-cultural adaptation (accommodation of
  environments to persons culture, and adaptation
  of personal skills and supports to environments).

81
Family and Culture - Exercise

• Ruth, a 33-year old Jewish orthodox woman
  diagnosed with schizophrenia and living with her
  Jewish orthodox parents, is torn between her plan
  for supported education and her parents plan to
  wed her as soon as possible.
• Identify cultural and family issues raised by
  this case, and suggest culturally-sensitive
  interventions addressing these issues. Establish
  relevant learning objectives for further study.

82
Case Management and other Environmental
Interventions

• Abraham (Rami) Rudnick, MD, PhD, CPRP
• Objectives - increase knowledge and skills
  related to case management and other
  environmental interventions in psychiatric
  rehabilitation.

83
Environmental Intervention in Psychiatric
Rehabilitation - Rationale

• Person-environment fit.
• Insufficient personal skills and supports.
• Support development, modification, coordination
  and maintenance (adapted from
  Anthony et al 2002).

84
Case Management - Principles(adapted from Pratt
et al 1999)

• Continuity (of care).
• Assessing (client needs).
• Planning (service plan).
• Linking (with services).
• Coordinating (services).
• Monitoring (of service delivery).
• Evaluating (client responses).
• Reaching out?
• Advocacy?
• Direct service?

85
Case Management - Models(Mueser et al 1998)
86
Societal Rehabilitation

• Legislation.
• Fund raising.
• Stigma reduction.
• Community advocacy and partnership (in
  healthcare, vocational, residential and other
  relevant environments).
• Support of caregivers.
• Professional accreditation.

87
Case Management - Exercise

• List services used by yourself.
• List personal skills and supports required for
  success in using these services.
• Suggest case management strategies relevant for
  persons who desire to use each of these services
  and lack these personal skills and supports.

88
Ethical Problems in Psychiatric
Rehabilitation

• Abraham (Rami) Rudnick, MD, PhD, CPRP
• Objectives - increase knowledge and skills
  related to managing ethical problems in
  psychiatric rehabilitation.

89
General Ethics and Healthcare ethics

• Ethics theory of morality.
• Morality valued/recommended behaviors or
  attitudes towards other (human) beings.
• Ethical problem conflict of values or of moral
  principles.
• Principlist bioethics autonomy, beneficence
  (and non-maleficence), justice and context
  (Beauchamp Childress 1994).

90
Ethical Problems in Psychiatric
Rehabilitation (adapted from Szmukler 1999)

• Privacy.
• Confidentiality.
• Coercion.
• Conflicts of duty.

91
Code of Ethics - IAPSRS (1996)

• Conduct and comportment
  High standards of personal conduct,
  proficiency, help individuals achieve their needs
  and wants, multicultural competence.
• Ethical responsibility to people receiving
  services Primary responsibility to persons
  receiving services, refrain from dual
  relationships, integrity in all professional
  relationships for optimum benefit of person
  served, support maximum self-determination of
  person served, respect privacy and
  confidentiality of person served.

92
Code of Ethics - IAPSRS (1996), cont

• Ethical responsibility to colleagues
  Treat colleagues with respect,
  courtesy, fairness and good faith.
• Ethical responsibility to the profession
  Uphold and advance the mission, ethics
  and principles of psychiatric rehabilitation,
  promote psychiatric rehabilitation as a primary
  service modality, identify, develop and fully
  utilize professional knowledge.
• Ethical responsibility to society
  Promote the general welfare of society
  by promoting the acceptance of persons with
  mental illness.

93
Ethical Problems - Exercise

• Read the case report (Rudnick 2002).
• Analyze the case report according to a bioethical
  principlist approach.
• Simulate an ethical committee discussion of the
  case report.
• Present your preferred ethical solution and
  reasons for it.