Patients Drive Goal Setting in Psych Rehab Program

Recovery from schizophrenia or other serious mental illnesses has been a goal of American mental health services for some time now. But it is also the goal of Canadian mental health services and those in many other countries, Abraham Rudnick, M.D., Ph.D., reported at the annual meeting of the Canadian Psychiatric Association in Toronto in September.

Rudnick is an associate professor of psychiatry and philosophy at the University of Western Ontario. All of his patients have refractory schizophrenia. He works with them on their recovery, particularly on psychiatric rehabilitation issues.

“Recovery is about having a meaningful life even if symptoms persist,” he explained. The goal of psychiatric rehabilitation is to help patients choose and pursue goals that will help them achieve a “meaningful” life, thus making psychiatric rehabilitation a key part of the recovery movement.

Psychiatric rehabilitation began to come into its own in the 1970s through the efforts of William Anthony, Ph.D., executive director of the Center for Psychiatric Rehabilitation in Boston, Rudnick noted. The field of psychiatric rehabilitation has since evolved into a unique discipline, is growing rapidly, has become evidence based, and has its own journals such as the Psychiatric Rehabilitation Journal.

“When it comes to helping a patient, or what we call a service user, with psychiatric rehabilitation, he or she drives the goals,” said Rudnick. “We help him or her work up a plan of recovery.”

For example, if a service user wants to live independently in an apartment, the challenge for Rudnick and his staff is to determine whether such a goal is realistic for that individual, and if so, how they can help that person achieve it. Some service users can live independently, while others can live in supported housing or group homes. Some need intensive support for life; others do not, he noted.

In another example he described, a service user wants to apply for a particular job, but does not function well in the morning because of the antipsychotic medications he has to take. Rudnick and his coworkers might suggest that he work out an arrangement with his prospective employer to start work around noon rather than at 9 a.m. “Many people on antipsychotics can work well if they start their work day around noon,” Rudnick said. “I have seen that happen again and again.”

Cognitive impairments, such as problems with attention or difficulty solving problems, are a bigger hindrance to the recovery of patients with schizophrenia than psychotic symptoms are, Rudnick also noted. Thus cognitive remediation is an important new area of psychiatric rehabilitation. Much of it is about compensating for, rather than correcting, such problems, and it can help lead to employment and other achievements.

Rudnick and his staff have experienced notable successes in their psychiatric rehabilitation efforts. For example, one service user with schizophrenia came to realize that he wanted to be a musician and a music teacher, and they helped him achieve it with job coaching and cognitive-behavioral therapy for dealing with psychosis.

Psychiatric rehabilitation is also being taken into some creative new directions, Rudnick pointed out. For example, he and his colleagues have been training people with mental health challenges to become stand-up comedians—not necessarily with the goal of finding work in the field, although some have done so, but to increase their sense of self-confidence and ability to use humor in various situations.

Even if psychiatrists do not want to become as involved with psychiatric rehabilitation as he has, they should still be partners in psychiatric rehabilitation efforts, Rudnick urged. “I think the most important thing that psychiatrists can do to help service users is to collaboratively plan care according to the users' life goals. This is the mainstay of facilitating recovery and commonly requires skills and resources that can be provided by others if the psychiatrist does not have the interest or ability to provide them.”

An excellent resource on psychiatric rehabilitation for psychiatrists, Rudnick added, is the Web site of the U.S. Psychosocial Rehabilitation Association at <www.uspra.org>. That organization will hold its next annual meeting in Boston in June 2011.