xxAACP Newsletter, Volume 13, Number 3, Summer 1999

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AACP Develops Guidelines For Psychosocial Rehabilitation

INTRODUCTION

The AACP Committee on Psychosocial Rehabilitation was formed to assist the APA Presidential Initiative Committee on Psychosocial Rehabilitation or the Chronically and Severely Mentally Ill by offering the recommendations of a group of interested and active clinicians. The AACP is a logical contributor to this effort as psychosocial rehabilitation holds a central place in the daily work and professional values of most of its members. An abbreviated version of the document is presented below. The full document was presented to the APA and will be issued as part of the Committee’s report.

The AACP committee developed six issue statements that follow a list of organizing precepts.

ORGANIZING PRECEPTS

1. Psychosocial rehabilitation has been defined as "a therapeutic approach that encourages a mentally ill person to develop his or her fullest capacities through learning and environmental supports. Psychiatry must embrace this concept as part of healing, and especially adopt it as a basic premise in the profession’s work with people who have severe mental illness. In fact, this is so critical that the profession must actively participate in its development.
2. Psychiatrists engage and then build relationships with mental health consumers and, in collaboration with other professionals, help their patients articulate and accomplish their personal goals.
3. Psychiatrists employ a biopsychosocial model to guide the categorization of goals and to understand their interaction.
4. As physicians, psychiatrists are often in leadership roles while engaging in goal planning among professionals.
5. The components of planning constantly developing rehabilitative goals lie on a spectrum from traditional services to nontraditional community resources. Traditional psychiatric tools, like diagnosis, psychopharmacology, psychotherapy, inpatient hospitalization, and health evaluation are discrete interventions within the broad rehabilitative paradigm. Even the employment of a biological intervention such as antipsychotic medication (especially the so-called atypicals) can serve a valuable purpose in enabling a person to be accessible to psychosocial rehabilitation techniques.
6. Psychiatrists who work longitudinally with patients with severe psychiatric disorders also understand how to coordinate these interventions with the creative use of other resources in pursuit of enhancing functioning, fostering hope, and helping a person create meaningful identity. Examples of these resources are cognitive rehabilitative services, social skills training, vocational treatment of co-occurring chemical dependency, specialized housing, peer support mechanisms, and healing modalities that derive from cultural values and spiritual concerns.

ISSUES

#1 The relationship of psychiatry to others who work in psychosocial rehabilitation.

• Stronger alliances must be made among the professions that have defined expertise in psychosocial rehabilitation.
• Psychiatry must collaborate in research that shows the cost effectiveness of rehabilitative approaches.

The APA must reach out to professional rehabilitation organizations to maximize funding opportunities, increase visibility for psychiatric rehabilitation, and to explore opportunities to collaborate in developing the research agenda. Organized psychiatry and allied professional groups must advocate the blending of funding streams by policy planners. An example is a blending of funding for housing and treatment through capitation.

#2 Psychiatry’s support of technologies defined as psychosocial rehabilitation.

• Psychiatry must assure that rehabilitation techniques have demonstrable efficacy as evidenced by scientific method.

The APA must be more outspoken in support of psychosocial research. Epidemiological studies, for example, of mental health issues in impoverished populations, should be a priority. The APA should lobby all major grantors, and perhaps especially pharmaceutical companies, to fund psychosocial research in the context of treatment with medications.

#3 How clinical psychiatrists involve themselves in psychosocial rehabilitation.

• Psychiatrists must be active in the planning and prescription of rehabilitation.
• Psychiatrists must focus on the patient’s own goals.

Educate psychiatrists about rehabilitation. Teach administrators and allied professionals that psychiatrists can operate from collaborative and broad-based (biopsychosocial) models. The APA should take the lead in developing support for ethical practice in comprehensive programs. Through alliances with consumer and family organizations, psychiatrists should lead in the education of staff and in linking service programs with consumer organizations. The APA must advocate and lobby for the creation of independent ombudsman offices in public sector managed care organizations

#4 The orientation of psychiatric administrators toward psychosocial rehabilitation.

• Psychiatrists must practice within a continuity of services that provide assistance throughout life.
• Psychiatrists must develop effective relationships with community resources.

Vision and courage must be stimulated. Administrators must look at what will benefit the entire system of care over the long run and avoid responding only to immediate budget pressures. Psychiatric administrators need to plan services along a full continuum, an approach known ultimately to be cost effective. Administrators must work their local political environments to assure adequate funding. Psychiatric administrators must become familiar with their local communities in order to develop culturally sensitive programming. Psychiatric administrators should cultivate both local mental health and non-mental health resources to create collaborations with grass-roots organizations like church and neighborhood service groups.

#5 How academic programs must address rehabilitation.

• Continuing education for practicing psychiatrists must include psychosocial rehabilitation.
• Psychiatric residents must be offered systematic education in psychosocial rehabilitation.
• Medical students must have the opportunity for training in psychosocial rehabilitation.

APA annual meetings should feature the relevance of psychosocial rehabilitation in appropriate patient populations. Industry symposia should include psychosocial rehabilitation in the presentations on pharmacotherapy. The AACP’s Model Curriculum for training residents in community psychiatry should be used as a starting point in the development of relevant and realistic rotations. The initiatives spurred by Ken Thompson (AACP Board Member) and fostered by the AACP to teach, stimulate and include members of AMSA and NMSA should be studied, nurtured and replicated. If needed, experienced non-psychiatric professionals can be brought into training programs to augment the community psychiatry faculty, and the roles of medical directors and staff psychiatrists in psychosocial rehabilitation can be highlighted didactically.

#6 Psychosocial rehabilitation’s role in managed care environments.

• Managed behavioral healthcare organizations must have medical directors who define clinical appropriateness and necessity in the planning and funding of covered interventions.
• Psychiatrists working in organized systems of care must have the authority commensurate with their responsibility to provide effective interventions based on individual patient’s needs.

Public sector managed care must be carefully regulated. An independent ombudsman office will facilitate monitoring. Managed care contracts should have meaningful and realistic quality assurance components. Financial incentives for good outcomes and penalties for bad outcomes must be introduced.

For further information, contact Hunter McQuistion, MD at hottod@aol.com.

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