REHABILITATION (Psychiatric)

Rehabilitation may be defined as the process of helping an individual who has had a physical or mental disorder to participate in society to the fullest extent of his capacities. It is often described as the fourth phase of medical practice, the others being prevention, diagnosis and treatment.In general medicine rehabilitation usually designates “that phase of care during which the patient is helped toward an independent role in competitive society. Rehabilitation follows the curative and restorative medical program and the period of convalescence. Rehabilitation seeks to overcome and compensate for an existing physical handicap and for the emotional blocks that prevent the patient from doing his best. The major emphasis is on occupational self-sufficiency” (Braceland, 1966). In psychiatry—and to a growing extent in physical medicine—the emphasis is not only on vocational performance, but on social adjustment as well: “The successfully rehabilitated patient is one who is able to live in a nonmedical setting at a level of occupational performance comparable with other adults in the community” (Freeman and Simmons, 1963). The term implies that residuals of psychiatric disorder may remain after treatment; the rehabilitative process is designed to cope with them and keep them from interfering with social and occupational activities.Historically speaking, the “moral treatment” applied in the mental hospitals of a century ago was essentially a form of rehabilitation, since it emphasized the value of occupational, educational, and social activities carried out in an optimistic environment. This approach, however, was abandoned when the view that mental illness was due to incurable brain disorder became dominant, and as a result mental hospitals became largely custodial institutions. But in the last thirty years, effective treatment techniques have been developed, and it has become an accepted fact that if they are fully applied, most patients can recover sufficiently to lead an active and constructive life in the community. At the same time it has also become apparent that rehabilitative measures should not be postponed until the patient is out of the hospital, but should be an integral part of the treatment process itself. See MENTAL HOSPITAL, RAY, KIRKBRIDB.Since specific rehabilitative activities and facilities are discussed under separate topics, we will do little more than enumerate them here, following Braceland’s classification into in-patient and community rehabilitation. The inpatient process has the double aim of preventing the development of a “disability syndrome” or “institutional neurosis” characterized by apathy, withdrawal, and resignation; and of preparing the patient for social and occupational participation in the community when he leaves the hospital. The institution as a whole is organized as a “therapeutic community” directed toward the recovery and the rehabilitation of the patient. Every member of the staff is viewed as a contributor to this process, and free and open communication is encouraged at all levels. The patients themselves participate in discussion groups, committee activities and self-government. Even the physical arrangements are designed to stimulate socialization: large wards are broken up into small units and many individual rooms are available for the various patient activities. The scope of the activity program has been widened to include practically every conceivable way of broadening the patients’ interests, helping them to use their time constructively, and increasing their confidence and skill. Among the activities are handcrafts, dramatics, art classes, music therapy, dance therapy, occupational therapy, industrial therapy (paid work), patient clubs, recreational therapy, and outside employment as a transitional step to the community. See MILIEU THERAPY, RECREATIONAL THERAPY, OCCUPATIONAL THERAPY, ART THERAPY, DANCE THERAPY, MUSIC THERAPY.The goal of community rehabilitation is to provide a bridge to normal life for the patient who has been released from residential treatment. Transitional facilities and after-care programs have multiplied in recent years, though they are still unavailable in many localities. They include: day hospitals, providing all types of psychiatric treatment and all rehabilitative activities on a day basis; halfway houses, where patients may live during the readjustment period, including not only group residential centers but subsidized apartments supervised by social workers, such as Horizon House in Philadelphia and Quarters House in San Jose; occupational rehabilitation under the Federal-State rehabilitation system and private organizations, providing vocational counseling, job-finding, and placement in industry or in sheltered workships; ex-patient clubs for social and therapeutic purposes, run by either the patients themselves or the hospital as part of its after-care program; foster-family care in carefully selected families under the supervision of a social worker and visiting psychiatric nurse; family care in the patient’s own family, with the assistance of psychiatric or public health nurses and social workers who work with the family as well as the patient. See DAY HOSPITAL, NIGHT HOSPITAL, HALFWAY HOUSE, SHELTERED WORKSHOP, FAMILY CARE, MENTAL PATIENT ORGANIZATIONS, HEAD INJURY (CHRONIC TRAUMATIC DISORDERS), NURSERY SCHOOL EXPERIENCE, SOCIAL BREAKDOWN SYNDROME.