Psychosocial rehabilitation. The recovery model in mental disorders. Psychoeducation

01Aims and history

Psychosocial rehabilitation is the process of helping people with severe and enduring mental illness, most often schizophrenia and other psychoses, to live as independently and fully as possible. It works on what drugs do not fix: negative symptoms, cognitive impairment, lost skills, unemployment, isolation and the disadvantages that come with a psychiatric history.

In the UK, NICE's rehabilitation guideline describes the people who need it as having complex psychosis: severe, treatment-resistant symptoms with functional impairment, often with cognitive problems, substance misuse, a neurodevelopmental condition or physical illness, and repeated or long admissions.

From asylum to community

1. 1950s

   The asylums at their peak

   The mental hospitals of England and Wales hold about 150,000 patients at their peak in 1954; long-stay patients live in large, remote hospitals.

2. 1959–70

   The harm of institutions

   Russell Barton's institutional neurosis, Erving Goffman's Asylums (1961), and John Wing and George Brown's three-hospital study show that understimulating wards produce apathy and withdrawal.

3. 1961

   The Water Tower speech

   England's health minister Enoch Powell announces the run-down of the asylums, helped by the new antipsychotics.

4. 1975

   Psychiatrie-Enquête

   A West German parliamentary report exposes conditions in the hospitals and starts reform towards community services.

5. 1978

   Law 180

   Italy's Basaglia law stops admissions to psychiatric hospitals and replaces them with community mental health centres and small units in general hospitals; the last asylums close in the late 1990s.

6. 1980s–90s

   Care in the community

   Most long-stay hospitals in the UK close and those elsewhere in western Europe shrink; community mental health teams take over much of their work.

Deinstitutionalisation largely worked for the long-stay patients it moved: followed up after the closure of two London asylums, most were living in community homes, preferred them, and rarely became homeless or offended. But it was often underfunded. Some people who would once have been in hospital now drift into homelessness or prison, and since the 1990s many European countries have expanded forensic beds and supported housing while cutting general psychiatric beds, a pattern called reinstitutionalisation.

02Components of rehabilitation

Rehabilitation is planned with the person, around their own goals, by a multidisciplinary team that includes occupational therapists, nurses, psychologists, social workers, psychiatrists and, increasingly, peer workers.

Skills and cognition

Cognitive impairment, slower processing, poor memory and weak executive function, predicts functioning in schizophrenia better than positive symptoms do, and antipsychotics do not improve it. Cognitive remediation works best with an active, trained therapist, explicit strategy teaching and a bridge to the person's real tasks.

Work

Most people with schizophrenia want to work, yet in Europe only a small minority do; unemployment rates of 80 to 90 per cent are common. Work brings income, structure, identity and contacts, and does not increase relapse.

IPS rests on a few principles: anyone who wants to work is eligible, whatever their symptoms; the goal is competitive employment; the employment specialist is part of the mental health team; the job search starts within about a month; jobs follow the person's preferences; advice on welfare benefits is given; and support is not time-limited. In the EQOLISE trial in six European centres, 55 per cent of people in IPS worked at least one day over 18 months, against 28 per cent with the best local vocational services, and they were less often readmitted to hospital.

Housing

Stable housing comes before most other goals. The usual pathway steps down in support:

Housing First reverses the order for homeless people with mental illness: it offers a permanent home of their own straight away, without first requiring treatment or abstinence, with intensive support from a team. Trials in North America and France found more people stably housed, and Finland, which made Housing First national policy, is one of the few European countries where homelessness has fallen steadily.

Community teams

ACT was developed in Madison, Wisconsin in the 1970s and cut admissions in the USA, where community services were weak. In London, the REACT trial found no advantage over ordinary community teams, which already worked well: intensive teams help most where hospital use is high. Flexible ACT, developed in the Netherlands and since taken up in Norway and Denmark, has one team move each patient between ordinary case management and assertive team care as their needs change. Early intervention improved outcomes in the Danish OPUS trial, though some benefits faded once the service ended. Open Dialogue, from Finnish Western Lapland, meets the person and their network within a day of a crisis; the evidence from controlled trials is still limited.

03The recovery model

Clinical and personal recovery

The recovery movement grew from the 1980s out of the writing of people with lived experience of mental illness. It redefines success:

A systematic review of 97 papers summarised the processes of personal recovery in the CHIME framework:

Recovery in services

Recovery-oriented services hold hope for the person when they cannot, share decisions, focus on strengths and goals rather than deficits, and support self-management. Staff pessimism is a real obstacle: clinicians see people when they are most unwell and rarely see those who recover.

• Peer support workers are people with their own experience of mental illness, trained and employed to support others. They model recovery and hope; in the UK CORE trial, peer-supported self-management after crisis care reduced readmissions within a year.
• Recovery colleges run courses on living with mental illness, written and taught jointly by professionals and people with lived experience, open to patients, families and staff as students rather than patients.
• Self-management programmes teach people to recognise warning signs, use coping strategies and plan for crises.

04Stigma

Stigma has three parts: ignorance and stereotypes, a problem of knowledge ("people with schizophrenia are violent"); prejudice, a problem of attitudes; and discrimination, a problem of behaviour that excludes. It works at three levels: public stigma; self-stigma, when people with mental illness come to believe the stereotypes, lose self-esteem and stop trying; and structural stigma, in laws, insurance, funding and the way services are run.

of people with schizophrenia in 27 countries reported discrimination in making or keeping friends

47per centof people with schizophrenia in 27 countries reported discrimination in making or keeping friends

felt they had to conceal their diagnosis

72per centfelt they had to conceal their diagnosis

Its effects are concrete: people delay seeking help, lose work and housing, and receive worse physical care, when new symptoms are put down to the mental illness, called diagnostic overshadowing. Stigma comes from health professionals as well as the public, and many patients describe it as harder to bear than the illness itself.

Clinicians can help directly: use person-first language ("a person with schizophrenia", not "a schizophrenic"), challenge their own and colleagues' prejudices, and take physical complaints seriously.

05Psychoeducation

Psychoeducation gives patients and families information about the illness, its treatment and how to manage it, but it goes beyond a leaflet: it builds understanding, coping and relapse prevention, often in groups, and works best when interactive and repeated.

Expressed emotion

In the 1950s and 60s George Brown and colleagues in London found that men with schizophrenia discharged to parents or wives relapsed more than those discharged to lodgings. The key was expressed emotion (EE), the emotional climate of the family, rated from an interview with a relative, the Camberwell Family Interview.

Warmth and positive comments protect. Across studies, about half of patients in high-EE families relapse within a year, against about a fifth in low-EE families, and risk is highest with long hours of face-to-face contact and without medication. High EE also predicts relapse in mood and eating disorders. It reflects a stressed family coping with a hard illness, not a cause of schizophrenia, and families must not be blamed.

Family intervention in schizophrenia

Family intervention combines psychoeducation, communication and problem-solving training, and support for carers' own needs. It lowers EE, cuts relapse by almost half, improves adherence and may reduce admissions, though many of the trials are of modest quality. In the UK, NICE asks for it to be offered to all families of people with psychosis who live with or are in close contact with them, over three months to a year, with at least ten sessions, including the patient where possible.

Psychoeducation in bipolar disorder

In bipolar disorder, structured group psychoeducation, 21 sessions in a Barcelona trial of patients in remission, reduced recurrences and time in hospital, with benefits still evident at five years. It teaches the nature of the illness, adherence, avoiding drugs and alcohol, the importance of regular sleep, and early warning signs. Family-focused therapy and interpersonal and social rhythm therapy also reduce relapse.

A relapse prevention plan

1. 1

   Understand

   The person, and family if they agree, learn about the illness, its treatment and what helps.
2. 2

   Find the signature

   Identify the early warning signs from past episodes: poor sleep, withdrawal, suspiciousness or odd ideas before psychosis; less sleep, more energy and irritability before mania.
3. 3

   Know the triggers

   Stress, cannabis and other drugs, stopping medication, disrupted sleep and shift work, life events.
4. 4

   Plan the response

   What the person will do, what family will do, whom to call, any agreed change in medication, and how to reach the crisis team.
5. 5

   Write it and share it

   Record it, with the person's wishes for care in a crisis as an advance statement, give copies to those involved, and review it after any relapse.

06Physical health

People with severe mental illness die on average 10 to 20 years earlier than the general population; in schizophrenia, a meta-analysis found about 14.5 years of life lost. Suicide accounts for only part of the gap; most of it is physical illness, above all cardiovascular disease, respiratory disease, diabetes and cancer, and the gap has not narrowed while the health of the general population has improved.

Monitoring

For people taking antipsychotics, in the UK:

The responsibility is shared: the psychiatric team starts the checks, primary care continues them, and an abnormal result is treated, not just recorded. Treatment is the same as for anyone else: a healthier diet and activity, lipid-lowering and diabetes treatment, and a switch to an antipsychotic with fewer metabolic effects where possible. A European position statement from psychiatrists, diabetologists and cardiologists asks for the same standard of cardiovascular care.

Stopping smoking

People with mental illness want to stop smoking as much as anyone and can succeed with support. Nicotine replacement, varenicline and bupropion all help, varenicline the most; a large trial found no excess of neuropsychiatric harm with varenicline or bupropion in people with psychiatric disorders. UK guidance for psychosis offers nicotine replacement, varenicline or, in schizophrenia, bupropion, with a warning about neuropsychiatric effects and regular checks in the first weeks.