Historical and Conceptual Developments of

International Journal of Mental Health

ISSN: 0020-7411 (Print) 1557-9328 (Online) Journal homepage: http://www.tandfonline.com/loi/mimh20

Historical and Conceptual Developments of Psychosocial Rehabilitation: Beyond Illness and Disability in a Humanistic Framework Angelo Barbato & Barbara D’Avanzo To cite this article: Angelo Barbato & Barbara D’Avanzo (2016) Historical and Conceptual Developments of Psychosocial Rehabilitation: Beyond Illness and Disability in a Humanistic Framework, International Journal of Mental Health, 45:1, 97-104, DOI: 10.1080/00207411.2015.1132896 To link to this article: http://dx.doi.org/10.1080/00207411.2015.1132896

Published online: 13 May 2016.

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Date: 17 May 2016, At: 02:21

International Journal of Mental Health, 45: 97–104, 2016 Copyright # Taylor & Francis Group, LLC ISSN: 0020-7411 print/1557-9328 online DOI: 10.1080/00207411.2015.1132896

Historical and Conceptual Developments of Psychosocial Rehabilitation: Beyond Illness and Disability in a Humanistic Framework Angelo Barbato1 and Barbara D’Avanzo2

Downloaded by [Open University] at 02:21 17 May 2016

1

Laboratory of Epidemiology and Social Psychiatry, IRCCS, Istituto di Ricerche Farmacologiche Mario Negri, Milan, Italy 2

IRIS Postgraduate School of Psychotherapy, Milano, Italy

Abstract: Psychosocial rehabilitation is now coming of age and can no longer be considered as a subspecialty of psychiatry. It is therefore time to review its original foundations, past development, current status and future prospects. This paper outlines the history of psychosocial rehabilitation and its milestones: its first presentation in a textbook of psychiatry fifty years ago, the links with community care in early seventies, the conceptual framework provided by the WHO International Classification of Impairments, Disabilities and Handicaps in early eighties, the new challenges arising from the International Classification of Functioning, Disability and Health at the beginning of this century, the growth of the consumers movement and the breakthrough provided by the concepts of recovery and empowerment. The shift from a humanitarian to a humanistic standpoint can provide the foundation for an updated definition of psychosocial rehabilitation that considers social inclusion as its ultimate goal. Keywords psychosocial rehabilitation; disability; severe mental disorders; history; conceptual development

HISTORICAL AND CONCEPTUAL REVIEW In the very beginning, psychosocial rehabilitation entered the field of psychiatry, through the back door, about sixty years ago. Its roots could be traced back to the principles of physical rehabilitation and judicial sciences. In the first case, the goal was the restoration of functional abilities in persons whose autonomy had been limited by disease or trauma, while in the second case it was the restoration of civil rights and reintegration into the community of offenders who had served a term of imprisonment [1, 2]. The first official acknowledgment of rehabilitation as an area of psychiatry came with a report commissioned by the World Health Organization (WHO) to Maxwell Jones [3]. However, more than ten years went by before a chapter on rehabilitation appeared in a textbook of psychiatry: the American Handbook of Psychiatry, edited by Arieti in 1966, contained a short article by Braceland, outlining in a few pages the place of rehabilitation in psychiatric treatment [4]. Address correspondence to Angelo Barbato, Laboratory of Epidemiology and Social Psychiatry, IRCCS Istituto di Ricerche Farmacologiche Mario Negri, Via La Masa 19, Milan 20156, Italy; E-mail: [email protected].


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Early approaches were limited in scope, lacked a conceptual background, and were heavily influenced by the techniques and terminology of institutional care. In fact, long-term hospitalization was considered as an essential requirement for rehabilitation [5]. The first indication of a link between rehabilitation and community care came from the first international conference on psychiatric rehabilitation, organized in Helsinki in 1971 by the International Committee against Mental Illness. A number of speakers set forth life in the community as a goal of rehabilitation [6]. In his conference lecture, Basaglia presented a radical view of rehabilitation, by specifying that its targets were not only the individual, but also the psychiatric institutions and the social environment as a whole, to facilitate the integration of the mentally ill in the community [7]. Broader attention to the social impairments associated with mental disorders grew out as a result of the closure or rundown of large psychiatric hospitals and was reflected by the inclusion of deterioration in social and occupational functioning among the diagnostic criteria of DSM-III for schizophrenia [8]. A step forward in the same direction was the application to mental health of the conceptual framework provided in 1980 by the WHO through the development of the International Classification of Impairments, Disabilities and Handicaps (ICIDH) [9]. The ICIDH was conceived as a companion to the International Classification of Diseases and considered disablement as a consequence of diseases, hierarchically stratified in three levels along a continuum: impairment, defined as any loss or abnormality of psychological, physiological, or anatomical structure or function; disability, defined as any restriction or lack of ability resulting from an impairment to perform an activity in the manner or within the range considered normal for a human being; and handicap, defined as a disadvantage, resulting from an impairment or a disability, that limits or prevents the fulfillment of a role that is normal, according to age, sex, and social-cultural factors, for a given individual. Although experts in mental health did not participate in the preparation of ICIDH [10], the potential usefulness of its conceptual framework for clarification of rehabilitation’s role in the policy and practices of mental health care was understood at the outset by some groups of mental health professionals, especially in Europe [10]. Despite some overlap and redundancy between psychiatric diagnosis and disability, the disability itself and the handicap resulting from the interaction between the ill person and the environment could both be considered the targets of rehabilitation, and not the illness. Therefore, psychosocial rehabilitation could be defined as an autonomous field, not as a subspecialty of psychiatry. ICIDH paved the way for a clear definition of psychosocial rehabilitation, later introduced by a joint statement of the WHO and the World Association for Psychosocial Rehabilitation [11], a process that facilitates the opportunities for individuals impaired, disabled, or handicapped by a mental disorder to reach their optimal level of independent functioning in the community. It was specified that it implied both the improvement of individual competences and the introduction of environmental changes, stressing individuals’ choices on how to live successfully in the community. However, after a while, some limitations of ICIDH became the focus of a growing concern and attracted a number of criticisms, especially from self-advocacy movements, including the fast growing associations of mental health consumers [12]. The focus of criticism was, first, the identification of a direct linear link between the three levels, encompassing an unavoidable


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causal connection between the disease and the individual’s disadvantage, and also the failure to capture aspects of the individual not specific to the illness experience. Dissatisfaction with the shortcomings of ICIDH, widespread not only in the mental health field but in the rehabilitation field as a whole, led the WHO to move toward a new approach incorporating the suggestions of the consumers and advocacy associations. This time, a broad representation of mental health was included in the process, through the establishment of the International Mental Health Task Force as an umbrella organization [10]. The outcome was the drafting of the International Classification of Functioning, Disability and Health (ICF), officially endorsed in 2001 [13]. This new tool shifted the focus from a disease-oriented and professional-dominated approach to an etiology-free one that looked beyond the individuals’ impairments and acknowledged that function, behavior, and quality of life were essential to the individual’s experience of health and were linked in a recursive loop, thus moving past the linear and hierarchical approach of ICIDH [14]. Two aspects of the ICF conceptual framework are particularly important for mental health: universality, i.e., the view of disability as a feature of human condition affecting everybody in some way at a certain point in life and not only specific groups; continuity, i.e., the view of disability as a dimensional, not a categorical phenomenon existing along a continuum based on the interaction between health, social, personal, and environmental factors [15]. The inclusion of the ‘‘activities and participation’’ component acknowledged that functional status and social participation were key components of life. By paying attention to the environmental and personal factors that influence human functioning, the ICF not only recognizes the variability in experiences depending on an individual’s circumstances, but can help create a broader and more meaningful picture of the health experience of people and populations compared to the purely biomedical approach. This makes it possible to identify the person’s needs beyond those described in the diagnosis, helping providers and consumers identify functional goals and prioritize treatment selection.

NEW CHALLENGES The introduction of ICF was a conceptual breakthrough whose consequences for psychosocial rehabilitation are not yet fully understood [15]. In addition to ICF, however, other challenges to the theory and practice of rehabilitation in mental health care have come from a number of converging lines of evidence in the last years. Increasingly refined population studies have reported that the prevalence of unusual and bizarre perceptions or beliefs, commonly placed under the heading of psychotic symptoms, is higher than the prevalence of psychosis, with a continuum of symptoms in the general population [16]. Although the rates vary widely across countries and cultures, the findings of symptoms prevalence ten times or more than psychosis prevalence are fairly uniform, showing that severe mental illness exists in the general population as a continuous phenotype rather than as an all-or-none phenomenon. Moreover, in a number of cases psychotic experiences are self-limiting and not associated with subjective distress, help-seeking behavior, or social impairment [17]. This has at least two important implications. First, even illness, not only disability, needs to be understood as a dimensional variable. Second, symptoms and


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functioning, although related, should be seen as independent variables; low functioning is of concern even when not accompanied by symptoms given the public health and socioeconomic burden it causes. In agreement with this, the core link between illness and disability is in fact undergoing a thorough revision. The WHO suggestion is to disentangle the symptom and disability dimensions in the diagnosis of mental illness, so that the two dimensions and their relationship can be better defined and studied [18]. In this line of reasoning, illness and disability are two separate constructs, whose relationship should be considered part of the problem of each individual. Therefore, the focus of rehabilitation must be functional improvement and social inclusion, not necessarily related to the chronic illness course. First, problems in social functioning show up at the very first onset of mental disorders, and often even years before onset, raising the need for early rehabilitation approaches [19]. Even in acute stress disorders in the aftermath of disasters, timely psychosocial rehabilitation should be provided to prevent the development of post-traumatic stress disorders [20]. Second, studies of the long-term course of severe mental disorders show that, in a subgroup of cases, recovery is possible even after many years of illness [21]. Moreover, functional recovery can occur even without clinical recovery and vice versa [22]. In early rehabilitation of people at high risk or at onset of psychosis, interventions to help them start or return to work are vital and are suggested in the latest updates of the early intervention model. An approach based on supporting the individuals in job seeking in the open labor market (the so-called Individual Placement and Support model) has been found more effective than the traditional vocational training model, where previous assessment and long training are the core components [23]. This model consists of a direct and individualized search for work and an effort to support people at work (place-and-train), in contrast with gradual acquisition of skills to be checked before placement, often in sheltered settings (train-andplace). Although there are practical reasons to endorse a place-and-train model-–or at least to mix it with train-and-place–-there are several barriers to its implementation, often in the mental health system. In an ecological perspective, barriers themselves can be the target of rehabilitation. An important issue is the providers’ attitude toward the risk the consumer might run when placed in the labor market. A recent report showed that an intervention addressing the negative views of clinicians, often more concerned about the impact of work-related stress on the risk of relapse than the psychological, social, and financial benefits associated with rapid access to employment, led to more people attaining open employment [24]. The need to change professionals’ views to improve the outcome of rehabilitation is confirmed by careful examination of findings on long-term antipsychotic drug treatment. Symptomatic relapse is commonly considered the main adverse outcome to be prevented. Therefore, reducing relapse risk is the priority in psychiatrists’ work. This is so at least partly because the relapse is a hard outcome indicator—easy to count, sufficiently similar across cultures and systems, and frequent enough to show differences when these occur. The habit of comparing interventions and strategies on relapse may nonetheless prevent research from taking new roads and valuing more meaningful aspects of people’s life. A recent study found that relapses at two years were more frequent in subjects randomized to antipsychotics prescribed according to a dose reduction/discontinuation regimen than those randomized to maintenance treatment, but at seven years the two groups did not show



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any difference in relapses, and functioning was significantly better in those in the dose reduction/discontinuation group [25]. In commenting these results, some advocates of early intervention went even further, encouraging strategies aimed at maximizing early functional recovery, specifying that it is worth paying the cost of somewhat elevated rates of symptomatic relapse [26]. In our view, this means that i) when functioning is addressed more directly, more relapses can occur, but this would not be dramatically negative, and ii) the risk can be run, because the risk of symptomatic relapse can be managed with other tools, such as cognitive therapy. This attitude would have the advantage of not concentrating too much on relapse prevention by laying more emphasis and putting concrete efforts into pursuing outcomes and objectives more meaningful in the person’s life. Hitherto, psychosocial rehabilitation was often marked by a generic humanitarian concern for the fate of the mentally ill. Although this helped to expose the violation of civil rights in many psychiatric facilities, it is time now to move beyond this paternalistic approach, by shifting from a humanitarian to a humanistic standpoint [27]. The humanistic approach keeps the human at the center. Humanism is defined as a basic construct, active in understanding and making the world, where the human being is a measure, and an end in himself, an active, creative, thinking, desiring, and loving force [28]. The term humanitarian refers to a spiritual and moral prompt in favor of the human being, particularly in front of suffering. Although it is a basic and highly valuable construct, the humanitarian approach to rehabilitation suffers from too narrow a view, grounded in feelings, and not often finalized to real social inclusion. The humanistic view entails a vision of human life and culture basically confident in human resources, thought, and rationality, by blending a scientific position with an ethical one based on overarching values. This means allowing the dimension of values to be included in science and practice. The Grading of Recommendations Assessment, Development and Evaluation (GRADE), introduced by the WHO to include values and people preferences in assessing the effectiveness of interventions and services, goes in the same direction [29]. The values considered in GRADE are social inclusion, protection of human rights and dignity, prevention of discrimination and stigma, avoidance of medicalization of social problems, promotion of individual and families’ capacity and skills, and any relevant values endorsed by the people involved in the care process. Such values are consistent with the basic principles of psychosocial rehabilitation. In the same vein, in a large WHO study exploring the characteristics that users have found most valuable in the mental health services, the concept of responsiveness emerged fundamental. Responsiveness in mental health care has to be measured by the system’s ability to remove the negative aspects associated with being mentally ill and undergoing medical treatment, by strengthening the individual’s rights in the context of the health care system. Responsiveness can be considered at least as important as the health outcomes in assessing the performance of mental health services [30]. Last but not least, the growth of the consumer movement in mental health care has provided new arguments to redefine psychosocial rehabilitation [31]. Consumers claimed that their lives cannot be left in the professionals’ hands and they are the only ones responsible for their choices, at the same time asking to be truly admitted to any realm of the social life. Although the positions, backgrounds, and demands of the consumers movement are varied, four substantial outcomes emerge from its development: a strong quest for a far-reaching innovation of

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professional culture and practices, a focus on subjective experience as a core aspect of any approach to mental disorders [32], the definition of empowerment as a tool for rehabilitation, a goal of rehabilitation, and a measure of rehabilitation outcome [33], and the view of recovery going beyond its clinical and even functional meaning, by encompassing the subjective wellbeing, the achievement of unique personal goals including areas often neglected by clinicians, such as spirituality, sexuality, or social role fulfillment [34]. All such issues are consistent with the above described humanistic frame of reference, which is for psychosocial rehabilitation essential to bridge the gap between consumers and practitioners. Research evidence and practical experiences show that even users with severe mental disorders can be involved in service planning and evaluation [35]. Therefore, their active participation in rehabilitation is a top priority.

CONCLUSIONS Several conceptual shifts have occurred – more or less acknowledged at different levels – which have made psychosocial rehabilitation a much more complex and mature discipline than its previous definitions. These shifts have all contributed to integrating and systematizing the view that social context and real life compose the field of rehabilitation. A central role in this sense should be attributed to the deep revision of the boundaries between illness, functioning, disability, and social inclusion, concepts that constitute the material of psychosocial rehabilitation. It should become clear that the ultimate aim of psychosocial rehabilitation is social inclusion and any confusion between it (to be approached ecologically) and personal and social functioning (to be addressed in an individual dimension) should be overcome. Although contributing to each other in various ways, they are distinct concepts. This can be better acknowledged in this updated definition: Psychosocial rehabilitation is a public health strategy operating at the interface between the individual, his/her interpersonal network, and wider social context. It aims at fostering social inclusion of people with mental disorders and helping them to enhance their social/interpersonal functioning, subjective well-being, and quality of life, by reducing the risk factors and raising the protective factors involved in the development and maintenance of social disabilities related to mental disorders. REFERENCES 1. Farkas, M. (2013) Introduction to psychiatric/psychosocial rehabilitation (PSR): History and foundations. Current Psychiatry Reviews, 9, 177–187. 2. Rotman, E. (1990) Beyond punishment: A new view of the rehabilitation of criminal offenders. Westport, CT: Greenwood. 3. Jones, M. (1952) Rehabilitation in psychiatry. Geneva, Switzerland: World Health Organization. 4. Braceland, F.J. (1966) Rehabilitation. In S. Arieti (Ed.) American handbook of psychiatry. New York, NY: Basic Books. 5. Saraceno, B., & Barbato, A. (1995) Evaluation of psychiatric rehabilitation. International Journal of Mental Health, 24, 93–104. 6. Gittelman, M. (1997) Psychosocial rehabilitation for the mentally disabled: What have we learned? Psychiatric Quarterly, 68, 393–406. 7. Basaglia, F. (1982) Riabilitazione e controllo sociale. In Scritti II: 1968—1980. Torino, Italy: Einaudi.



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