A meaningful day: integrating psychosocial rehabilitation into community treatment of schizophrenia

Being part of society, enjoying good family relations, a healthy lifestyle, or having a satisfying job . . . these are not just a collection of rehabilitation goals but are what most people aspire to. All too often, schizophrenia profoundly disrupts these expectations — social isolation is a daily reality for most people with psychotic disorders. The majority of people with psychotic disorders have lost essential life roles that normally provide self-esteem and meaning. Eighty-four per cent are separated, divorced, widowed or single; 85% are reliant on welfare benefits; 72% do not have a regular occupation; and 45% live in institutions, hostels, supported housing or crisis shelters, or are homeless.1 A psychotic episode also affects those involved with the person affected.1 The bewildering and distressing symptoms, admission to hospital and administration of medication, combined with lack of understanding, cause significant trauma for all involved.2 It is crucial that managing people with schizophrenia include integrated rehabilitation services that respond promptly and appropriately to the needs of the individual and the family.

Ideally, rehabilitation services should include: 3

• psychological treatments (eg, cognitive behaviour therapy), if appropriate;

• education about the illness and how to cope with symptoms and the effects of disability;

• family therapy;

• support for carers;

• psychosocial rehabilitation;

• accommodation and employment support;

• specific skills development;

• assistance to link in to community resources; and

• help to learn how best to manage and come to terms with the illness.

These all take time, and hinge on the presence and efficient coordination of committed teams.

The general practitioner can play a crucial role in promoting psychosocial rehabilitation for people with schizophrenia — whether acting independently or as part of a shared-care program with an Area Mental Health Service.

Morbidity and mortality are high among people with schizophrenia.4,5 Withdrawal from, and loss of interest in, the world around them, loss of ability and confidence to engage socially, side effects of medication (eg, weight gain, sedation), high smoking rates and low income all contribute to low levels of general health among these people,6,7 and further isolate them from the rest of the community.

Before any progress can be made in improving physical health, people with schizophrenia must be motivated to change.8 Their loss of interest in the world around them is often reflected by loss of interest in their physical condition. It is important that they receive as much encouragement as possible and that everyone involved is aware that progress may be very slow.

It should not be assumed that a person who has been given a diagnosis of schizophrenia will understand what it is. Furthermore, people are affected by the community's lack of understanding and stigma about the illness, and may be reluctant to accept the term "schizophrenia" if they associate it with a "split personality" or other false stereotypes of mental illness that are widely prevalent in the community.9

Family members and other carers need to be recognised for the role they play in helping maintain a patient's mental health and need to be included in the overall rehabilitation plan. It is also important that they receive education, support and training in how best to support the patient. As people tend to respond positively to recommendations made by their GP, it is important for GPs to know of and refer people to support organisations, as well as to generic carer support provided by the Carers Association. Family group therapy, when available, may substantially reduce symptoms and frequency of episodes in the patient, as well as improving the mental health of the entire family.10-13

Psychosocial rehabilitation is often the key to reintegration.14 Self-confidence is one of the first casualties of a psychotic episode, accompanied by the feeling of loss of control over one's life. Support to develop and achieve realistic goals is often the start of the process of recovery.

Once clinical interventions have stabilised symptoms, the sense of loss resulting from the illness can be depressing in itself. Patients feel confused and distressed by the illness itself, the intervention of crisis teams, and sometimes involuntary admission to hospital. Family members can inadvertently increase the sense of powerlessness by being overprotective and "doing for" rather than "doing with" the person.15 It is important that the person's dignity is not disabled through the process of engaging with the mental health system, and that the patient is treated with respect and as an adult at all times.16

An essential component of reintegration is an environment that promotes the individual's sense of control. Patients must be perceived and treated by all as playing an active role in their own rehabilitation.17 They need to feel that this is not just something else that "happens to them", but a support system to help them learn to pick up the threads of their life again.18,19

Too often the illness is the only thing "going on" in the person's life and all conversations seem to revolve around it. Social networks often fall away, and the only contact many people with mental illness have is with their treatment team and family. Loneliness, isolation and a sense of helplessness can trigger a relapse or a retreat to risky alternatives such as drugs and alcohol. Despite increasing the likelihood of relapse, these alternatives can seem attractive: not only do they "anaesthetise" the person to the experience of the illness and provide a sense of personal control, they may also provide a peer identity group (and one that is not defined by mental illness). It is therefore very important for treatment services to intervene early to displace this vacuum with positive activity, and for the person to become engaged with the wider community, not with the drug subculture or other people who take advantage of vulnerable members of society.

Federal-government-funded Carer Respite and Disability Employment services are widely available in Australia. Community-based psychosocial rehabilitation programs — such as day programs, outreach and supported accommodation agencies — are state funded, and ideally work in partnership with Area Mental Health Services to provide the individual with a continuum of care.20 Availability of these services varies widely between states and between different regions within each state.21 It is important for GPs to refer people consistently to such services. Information about locally available services can be obtained from the Area Mental Health Service or mental health branch of the state health department.22

The advantage of day programs, in particular, is that they are structured to meet the psychosocial rehabilitation needs of people with illnesses such as schizophrenia, and one of the primary goals of people accessing a day program is to make friends. Connecting and socialising with others can be the point at which many people stop stigmatising and thus isolating themselves. For people not confident enough, or unwilling, to access a day program, outreach support workers and volunteer organisations that match volunteers with clients can help reconnect the threads. Reviving and sharing people's interests helps to redefine their self-image and life plan.