Delivered on 27th December 2013 RINPAS, Conference hall

1. PSYCHOSOCIAL REHABILITATION OF
PSYCHIATRIC PATIENTS WITH SPECIAL
REFERENCE TO FAMILY AND COMMUNITY
DISCUSSANT
SNIGDHA SAMANTRAY
MPHIL CLINICAL PSYCHOLOGY

2. DISCUSSION

3. The present discussion shall be covered
under the following headings:
• Introduction
• The need for psychosocial rehabilitation
• Efficacy of psychosocial rehabilitation in psychiatric
disorders
• Efficacy of family based interventions
• Efficacy of community based interventions
• Evidence based psychosocial rehabilitation
• Issues
• Psychosocial rehabilitation versus pharmacotherapy
• Psychosocial rehabilitation of psychiatric disorders in India
• Future direction
• conclusion

4. INTRODUCTION

5. The presentation has already given us a brief idea about what
psychosocial rehabilitation is, its application, models,
intervention strategies and its basic framework.
We already know that Psychosocial rehabilitation is a PROCESS
initiated by a health or mental Health professional, in
collaboration with the patient’s family and community, and
supported by policy planners, focused on developing and
implementing an individualised programme that seeks to
MAXIMISE THE PATIENT’S ASSETS AND MINIMISE DISABILITIES
IN THE AREA OF SOCIO-OCCUPATIONAL FUNCTIONING,
centring around the philosophy of mobilising and utilising
resources available to the community, with the final objective
of mainstreaming the client.
The term psychosocial rehabilitation has become so pervasive in
the mental health field–indeed, so overused–that it has
become necessary to clarify what it is not from what it is.

6. What psychosocial rehabilitation is not?
Psychosocial rehabilitation is not same as psychiatric treatment:
for psychiatric treatment focuses upon Alleviating symptoms
and distress with the primary goal of symptom relief. On the
other hand psychosocial rehabilitation focuses upon the
disability that has been bought by the psychiatric illness with
the primary goal of role functioning.
It does not mean that the service must be provided by
psychiatrists or that it must use psychiatric treatment
methods. “Rehabilitation” reflects the focus of the approach:
to improve functioning in a specific environment. Practitioners
of psychosocial rehabilitation focus on treating the
consequences of the mental illness rather than just the illness
per se.

7. In analyzing the early conceptual differences between treatment
and rehabilitation, Louis Leitner and James Drasgow, 1972,
pointed out that in general, treatment is directed more
toward minimizing illness and rehabilitation more toward
maximizing health. Eliminating or suppressing an impairment
does not automatically lead to more functional behaviour.
Likewise, a decrease in disability does not automatically lead
to reductions in impairment, although this could occur.
The table on the next slide indicates how psychosocial
rehabilitation is different from other mental health services
(cohen et al, 1988)

8. SERVICE CATEGORY
DESCRIPTION OF THE
CONTENT IN THE PROCESS
DESCRIPTION OF THE
CONTENT IN THE PROCESS
Treatment
Alleviating symptoms and distress
Symptom relief
Crisis intervention
Controlling and resolving critical or
dangerous problems
Personal safety assured
Case management
Obtaining the services consumer
needs and wants
Services accessed
Rehabilitation
Developing consumers’ skills
Role functioning
Enrichment
Engaging consumers in fulfilling and
satisfying activities
Self-development
Rights protection
Advocating to uphold one’s rights
Equal opportunity
Basic support
Providing consumers basic needs
to survive
consumer Personal survival
assured
Self help
Exercising a voice and a choice in
one’s life
Empowerment
Wellness/ prevention
Promoting healthy lifestyles
Health status improved

9. THE NEED FOR PSYCHOSOCIAL
REHABILITATION

10. • By their very nature, mental illnesses are chronic and
relapsing and require a broad range of services, beyond just
pharmacotherapy. No treatment of mental disorder can be
considered as complete or adequate without giving due
consideration to rehabilitation or aftercare services
(Channabasavanna, 1987).
• The need for psychosocial rehabilitation arises out of the
increasing percentage of mental disorders across the globe.
• Severe mental disorders (SMI) figure among the 10 leading
causes of disability and burden in the world (who, 2001).

11. • An estimate based on extrapolation from household surveys
and which excluded homeless people and residents of
institutions such as nursing homes, prisons, and long-term
care facilities, stated that nearly 4.8 million people suffer
worldwide from severe and persistent mental illnesses and 10
million people suffer from serious mental illnesses (IAPRS,
1997).
• A worldwide estimate of the current and future impact of
severe mental illnesses has increased dramatically. A new
internationally used statistic called the DALY, the “disabilityadjusted life year,” is a measure of a year of healthy life lost to
a particular disease, either through premature death or
disability. The most significant result from measuring disease
by DALYs is the new prominence it gives to the negative
impact of severe mental illnesses. For example, major
depression, typically not mentioned in international health
rankings, is currently the fourth leading contributor to DALYs,
and is projected to be ranked as the second leading
contributor by the year 2020 (Knox, 1996; Karel, 1996).

12. • Up to 50% of persons with SMI carry a concomitant diagnosis
of substance abuse. The so-called young adult chronic
patients constitute an additional category that is
diagnostically more complicated. These patients present
complex patterns of symptomatology difficult to categorize
within our diagnostic and classification systems. Many of
them also have a history of attempted suicide. All in all they
represent an utmost difficult-to-treat patient population.

13. Case vignette
Simon’s journey into a rehabilitation service
Simon is in his early 40s. He has had a diagnosis of schizophrenia
for 15 years. He has been hospitalised five times, being
compulsorily detained three times. A prominent feature of his
illness is his unshakeable conviction that he is under constant
surveillance by a government organisation. He believes he is
followed wherever he goes and frequently sees people whom
he believes to be these agents on the street and in local
shops. Partly through fearfulness and partly through apathy,
he spends most of his time alone in his flat. He takes no
interest in his appearance or hygiene and has serious
problems managing the upkeep of his flat, on which he owes
a considerable amount of unpaid rent. He has not worked for
many years.

14. The view of some clinicians is that his is a pretty hopeless case. In
the course of the long illness, he has received all the usual (and
some not so usual) pharmacological and available psychosocial
interventions, to apparently little effect. Simon’s view is just as
bleak, if not more so. In the past 10 years he has had two
consultant psychiatrists, whom he has seen mostly during his
spells in hospital, and a string of trainee psychiatrists, seen
fleetingly in an out-patient clinic. His main contact has been
with a community psychiatric nurse but she moved away just as
he was beginning to believe someone might have had his
interests at heart. Conversations with mental health staff have
mainly concerned medication or been disapproving of his
lifestyle. He has picked up the air of hopelessness that
surrounds his case, noticing that the enthusiastic promises of
new treatments and new referrals (in which he had little faith
anyway) have long since dropped away.

15. Having been out of unemployment for many years, he does not
believe that he is employable or, indeed, able to work and
cannot see the point of attending a day centre to mingle with
strangers or to work without reward. He feels quite powerless
to do anything himself and has come to the view that there is
little anyone else can do for him.
SIMON IS IN AN URGENT NEED OF PSYCHOSOCIAL
REHABILITATION TO GAIN BACK HIS LOST CONFIDENCE,
AQUIRE THE DORMANT SKILLS WITHIN HIM ONCE AGAIN AND
TO JOIN BACK THE MAIN STREAM IN COMMUNITY.

16. EFFICACY OF PSYCHOSOCIAL
REHABILITATION IN
PSYCHIATRIC PATIENTS

17. • The outcomes of psychosocial rehabilitation are fairly unique
and specific relative to other mental health interventions.
Psychiosocial rehabilitation ultimately attempts to improve
role Performance or status in people’s living, learning,
working, or social environments. While there might be
important ancillary outcomes (such as symptom reduction,
increased skill performance, changes in service utilisation),
the goals of psychiatric rehabilitation services are changes in
role performance. (Anthony et al, 2002).
• Oriented toward the practical, psychosocial rehabilitation
teaches a patient how to access resources--such as health
services and housing availability--and regain independent
functioning. It also provides programs of enrichment or selfdevelopment, even basic support such as housing and food
(McGuire, 2000)

18. • The Maine-Vermont Longitudinal Comparison Study
(Harding, 2000) was undertaken over a period of 32-36
years and is possibly the longest study reported in the
literature of the field. It tracked the differences in
outcome between people with a psychiatric history in
two American states, Vermont and Maine. The major
difference in the experience of the two groups was that
in one state, Vermont, the participants received a
comprehensive model rehabilitation demonstration
program, while the Maine patients had received
traditional custodial care. In her results Harding reported
strong findings that people who had received
rehabilitation had both much stronger community and
work functioning, as well as substantially reduced
symptoms as compared to the ones who had received
traditional custodial care.

19. A Literature review on Clinical, social and cost-benefits of
psychiatric rehabilitation Services carried by Common
wealth of Pennsylvania, Dept of Public Welfare 1999,
analysed fifteen articles published between 1984 and 1998
that described and Evaluated psychosocial programs. Their
overall conclusion was that participation in the programs
improved ‘functioning’ of the participants. The most
commonly reported areas of improved functioning with
psychosocial rehabilitation were:
•
•
•
•
•
•
•
•
improved Global Functioning (5 of 6 studies),
increased Employment (10 of 12 studies),
increased Independent Living (7 of 10 studies),
Social/Community Adjustment (4 of 7 studies),
decreased Use of Community Resources (2 of 2 studies),
decreased Hospital Admission Rates (7 of 9 studies),
decreased Time in the Hospital (11 of 13 studies), and
decreased Mental Health or Societal Costs (9 of 9 studies)

20. • Another parameter indicating the efficacy of psychosocial
rehabilitation is its heavy service utilisation. This is supported
by studies of heavy service utilization, which have found that
10 to 35 percent of clinical psychiatric populations are heavy
users of services and consume 50 to 80 percent of total
resources (Kent et al 1995, 1994 and Hardley et al 1992).
However, membership in the category of heavy users changes
over time; it is not a consistent characteristic of individual
patients in a majority of cases and is influenced by social and
system factors as well as by the needs of individual patients
(Kent et al 1995).
• It is observed that there is a definite limitation to the domains
of social functioning, cognitive functioning, and
psychopathology in chronic schizophrenia patients who have
had no rehabilitation. Vocational rehabilitation significantly
improves these limitations, which in turn helps these patients
to integrate into the society so as to function efficiently in
their roles (Suresh Kumar, 2008).

21. • Mathai et al.1998 in an unique, but small case control study,
tried cognitive re-training of four detoxified male alcoholics
and compared it with four controls. At the end of six weeks
they found a significant improvement in information
processing, memory, and reduction of neuro-psychological
deficits.
They
concluded
that
neuropsychological
rehabilitation was effective in improving cognitive defects of
abstinent alcoholics.
Other side of the coin
Although the literature on the effectiveness of psychosocial
rehabilitation is convincing, a limitation is that the published
studies have examined intervention strategies individually
rather than in combination. Consequently, we do not know
which combinations and amounts of interventions produce
optimal effects for which subjects, nor do we know what the
additive population effects might be.

22. For example, individual differences in capacity and
responsiveness to currently available treatments have
been shown to vary considerably (Kopelowicz et al,1997
and Bell et al, 1996), and individual differences in prior
treatment and current medication usually have not been
analyzed. In addition, studies of supported employment
interventions have shown high dropout rates of 41 to 77
percent within six months, but they have not identified
client characteristics that predict success or failure other
than prior work history.

23. EFFICACY OF FAMILY BASED
INTERVENTIONS

24. • Numerous empirical evidences have shown that specific
family intervention and inclusion of family in treatment
and rehabilitation of chronic mentally ill patients can
hasten the good outcomes of the illness and lay of better
opportunities to the patients to inculcate the skills
important for life functioning (Dixon & Lehman, 1995)
• Evaluations of family based interventions have reported
that by adding them to regimen of medication and
customary case management produces substantially
better outcomes than the latter two alone (Pilling et al,
2002)
• Involving family in treatment process facilitates better
illness management (Kopelowicz et al, 2003).

25. • The schizophrenia patient outcomes research team (PORT)
has developed treatment recommendations for the care of
persons with schizophrenia and has categorically pointed that
the long term outcome of schizophrenia largely depends on
family’s attitude and behaviour towards the patients (Lehman
& Steinwachs, 1998)

26. EFFICACY OF COMMUNITY BASED
INTERVENTIONS

27. • It is noteworthy that community based treatment is well
ahead in the term of prognosis of chronically ill patients.
Outcome of home community based treatment has same
positive aspects like enhanced patients and their family
members satisfaction, improvement of symptoms and social
adjustment of the patients. Psychosocial rehabilitation is an
important component of community support systems for
persons with severe and persistent mental illness.
• Some studies on community based rehabilitation (CBR)
programs of schizophrenia in day care centres, sheltered work
shop and half way homes have shown improvement in
recovery for patients with long standing illness in area of
residual disabilities of slowness, lack of motivation and social
withdrawal because through this way patients get involved in
therapeutic process directly and accustomed with the social
institutions. They get their lost skill to adopt social situation
more quickly than other patient who had been treated in a
protected and isolated environment (WHO report 2001).

28. • Therapeutic strategies like mutual self help group, direct
participation in their (patients) own rehabilitation program
can provide more favourable outcomes to the patients with
long term illness. The relapse rate of alcoholic client’s
decrease with level of interpersonal skills of their counsellors
which is a follow up study after the 6, 12, 18 and 24 months. It
is also suggested that CBR with social skills training and
supportive environment give better outcome in mentally ill
patients. CBR through primary health program give better
outcome and benefit for large number of people through
mental health education and counselling and drug distribution
(WHO report, 2001).
• Community based rehabilitation (CBR) is a feasible model of
rehabilitation for people with schizophrenia even in
economically deprived settings, and that outcomes are better,
at least for those who are treatment compliant (chatterjee et
al, 2003)

29. EVIDENCE BASED PSYCHOSOCIAL
REHABILITATION

30. • The empirical base of the psychiatric rehabilitation
process draws its evidence base from several lines of
research. it is the person’s self-determined goals and the
presence of the skills and supports necessary to reach
those goals, rather than the person’s diagnosis and
symptomatology, that relates most strongly to
rehabilitation outcomes (Anthony & Farkas, 2009).
• Psychosocial rehabilitation in general and skills training in
particular, for both consumers and family members, are
intended to promote a range of outcomes (IAPSRS,
1995). These interventions have demonstrated success in
symptom reduction, community adjustment, relapse
prevention, medication compliance, and reduced use of
the hospital and other restrictive settings (Dobson et al,
1995, Smith et al, 1996, Moller et al, 1997 & Conners et
al, 1998).

31. • Cognitive skill remediation has shown promising results
in helping patients relearn basic information processing
abilities such as attention, concentration, and memory
(Cassidy et al, 1996, Corrigen et al, 1996 & Medalia et al,
1998), which are critical to the acquisition of other skills
and, in some approaches, are taught together with other
skills in an integrated program (Brenner et al, 1994).
Cognitive skill remediation has also shown success in
directly reducing psychotic symptoms (Corrigan et al,
1996).
• McFarlane and associates, 1992, showed that patients
who participated in an intensive case management
program that had a vocational and rehabilitation
orientation and provided family psychoeducation, had
significant improvement in community adaptation
compared with patients who received intensive case
management alone.

32. • Reviews and meta-analyses of family psychoeducation studies
show consistently strong outcomes for the mentally ill relative
(Dixon, 1995 & Mari, 1994), including reduced relapse
(Linszen et al, 1997), reduced psychotic symptoms
(McFarlane, 1995) and increased self-efficacy for the family
member (Soloman et al, 1996).
• Although evidence-based practices are indicated for all
persons needing psychiatric rehabilitation, Evidence-based
practices are validated by large-scale studies in which means,
standard deviations and statistical tests of mean differences
between treatment conditions obscure differences between
individuals that have profound implications for choice of
treatment. Decisions about the type and amount of treatment
must be made for each individual, considering their
uniqueness, responses to prior treatments and phase of their
illness. "One suit does not fit all". Evidence-based treatments
should be carefully selected .

33. ISSUES

34. Ethical issues
The four guiding ethical principles of medical practice, also
referred to psychosocial rehabilitation practice are the
following:
• Respect for autonomy of the client: it involves providing the
client the freedom of choice treatment and course of illness
after hearing the benefits, risks and costs of all reasonable
options.
• Non malfeasance: a Hippocratian code of ethic is an essential
rule, preventing the risks of treatment and iatrogenic harm.
This principle is often violated with the intention of “good”
treatment effect outweighing the “bad” effect.

35. • Beneficence: providing the form of treatment to the client
that would benefit him and would result in meaningful
outcome.
• Justice: related to the equal distribution of health care
resources, especially to those persons who are in greater
need.
Other ethical issues include:
• It is unethical if there is a breach of confidentiality e.g.
reporting patient’s “diagnosis” of treatment details to a
possible employer and when therapeutic work procedures are
videotaped or recorded for education or research purposes,
without a previous written informed consent, by the
rehabilitation service clients.

36. • Another important ethical issue is when the rehabilitation
staffs challenge the client’s system of cultural values and
beliefs, when in the rehabilitation process.
•
Another ethical issue arises when the client is not compliant
with the programme’s principles and regulations and when
aggressive behaviour of a client is directed towards other
members and staff, or a sexual misconduct causes problems
to others in the programme. It is the staff and the other
members of the programme, who will try to “treat” this
problematic behaviour and prevent harmful consequences
within the limits of Therapeutic Community principles.
• Ethical code violation exists when there is no service internal
policy, securing human rights of clients attending the
programme.

37. Legal issues
The following document the so called psychosocial rehabilitation
malpractice. They arise when there is:
• Incorrect psychosocial rehabilitation diagnosis of a client,
leading to improper service placement.
• Improper work supervision, exposing the client to possible
work risks.
• Failure of staff to monitor psychiatric care or prevent adverse
psychotropic drug side effects due to lack of
intercommunication between mental health care agencies
involved in the treatment and rehabilitation of the client.

38. • Building a psychosocial rehabilitation service programme,
with inadequate organization procedures, leading to
misdiagnosis, activities with no clear boundaries, improper
placement and supervision, are liable for malpractice claims.
• Employment of service personnel with inadequate specialized
training could jeopardize the successful rehabilitation
outcome and is liable for malpractice claims. However, there
is no evidence of malpractice when the client’s poor
rehabilitation outcome is not related to negligent
rehabilitation procedures.

39. Issues in special population
Children:
• Children are less able to express themselves in words hence it
becomes important to assess their developmental stages
appropriately for proper diagnosis and rehabilitation plan. Use
of psychopharmacotherapy is less common in children as
compared to adults hence their rehabilitation poses a great
challenge for therapists. In this instance care, should be
provided in a supportive environment with few restrictions
and be in units “streamed by phases of illness and
developmental stage” (McGorry et al, 2003).
• Confidentiality becomes an issue in child psychosocial
rehabilitation as parents always want to know what their
children are saying or doing (Madianos,2001)

40. Geriatric population:
• Cognitive functioning in older adults is the major issue that
interferes with the outcome of rehabilitation programme.
Increasing age may be associated with reduced brain plasticity
and responsiveness to cognitive rehabilitation, perhaps
diminishing the impact of a psychological intervention in older
people (McGurk & Mueser, 2008)
• There is an urgent need to integrate health promotion, health
care, and illness self-management interventions into
psychosocial rehabilitative interventions for older adults.
Finally, strategies are needed that address the “whole person”
as an integrated approach to psychosocial rehabilitation for
older adults with SMI, including both the mental and physical
health needs (Bartels, 2004).

41. Rural population:
• Staff turnover in rural and remote regions due to various
geographic factors can represent a barrier to the
establishment of a consistent service culture, creates an
ongoing orientation training requirement and can adversely
affect continuity of case management.
• A further issue identified was the inequity of resource
distribution that can result when there is a limited response
to tenders for non-government services in rural and remote
regions.

42. People from Culturally and Linguistically Diverse Backgrounds
• The sociocultural diversity poses both a problem and a
challenge. Psychosocial interventions have to be geared to the
individual needs of the patient and their family and keeping in
mind their sociocultural background (Kapur, 1992).
• Language barriers also interfere significantly with psychosocial
interventions. There is a need for culturally sensitive
assessment tools and inventories along with appropriate
training to the staff members.

43. Other issues
• Personnel issues: While programs may refer to themselves as
rehabilitation programs, and systems may consider
themselves rehabilitation oriented, if the personnel are not
trained and experienced in rehabilitation, then rehabilitation
will not be practiced. The simple fact is that professional
schools of psychology, social work, nursing, psychiatry,
occupational therapy, and rehabilitation counseling are not
training their students in psychiatric rehabilitation. Effective
implementation of psychiatric rehabilitation as part of mental
health systems requires that it be taught within professional
training programs (Cohen, 1985).

44. • Program issues: Skilled personnel need to practice in
programs that allow them to use their skills. Although the
programs may be called “rehabilitation,” they may not be
psychiatric rehabilitation programs at all. Policymakers need
to know what constitutes a psychiatric rehabilitation program
and develop quality assurance mechanisms to ensure that
programs identified as such accurately reflect the principles of
the field (Anthony, 1992).
• System issues: One of the most significant policy concerns is
that the various system functions (planning, funding,
management, program development, human resource
development, coordination, evaluation, and advocacy) work in
concert to implement a psychiatric rehabilitation initiative.

45. While each system-level function must eventually be
compatible with psychiatric rehabilitation, all of these system
functions will not begin to change at the same time nor with
the same intensity. Policymakers who are initiating a
psychiatric rehabilitation approach within their systems
should start with those system functions in which personnel
seem the most eager to change, as well as those functions
that are currently most compatible with the new direction
(Anthony,1992)
• Recovery oriented approach: Recovery from mental illness is a
highly complex, individualized process. It is assumed that
individuals with serious mental illness can recover and have
productive work lives, satisfying relationships, and greater
meaning in their personal lives (Torrey et al, 2005). There is a
dire need for our current mental health system to become
more recovery oriented (Anthony, 2000) for the affected
individuals to recover in a meaningful way.

46. • The pervasiveness of mental illness and the heterogeneity of
mental illness becomes a major issue for psychosocial
rehabilitation (Iyer, 2005).

47. Issues in Indian context
• In India economic constraint is the major issue. At the
governmental level, policy makers have been unable to
devote serious attention to the development of rehabilitation
services for the chronic mentally ill primarily due to economic
constraints (Srinivasa Murthy,1989).
• Studies have shown that in India, families are more tolerant of
deviant behaviour and more willing to take care of the ill
member (Bhatti et al, 1980; Wig et al, 1987). However,
increasing urbanization and lifestyle changes, like the nuclear
family system and shrinking social networks, are leading to
high distress and burden of caring of the ill (Gopinath &
Chaturvedi, 1992).

48. • Hospital based services are increasingly being made available,
however there is an urgent need for more day care centres
that can provide the much needed respite for the family as
well as make the individual patient feel less stigmatized and
more valued (Rao et al, 1988).
• In India, there is a need to emphasize vocational training in
day care centres, so that patients can relearn or retrain in
marketable skills (Nagaswami et al, 1985), as the patient may
often be the sole breadwinner or is at least expected to
supplement the family income.
• In India a certain percentage of patients are 'non responders'
to treatment and run a downhill course. Provisions have to be
made for their long term, residential care. It is essential that
such services are not limited to the 'haves', but available to all
those who most need it. For this purpose psychosocial
rehabilitation has to be made cost effective (Bond, 1984).
• The sociocultural diversity in India poses both a problem and
a challenge. Psychosocial interventions have to be geared to
the individual needs of the patient and their family and
keeping in mind their sociocultural background (Kapur, 1992).

49. PSYCHOSOCIAL REHABILITATION
VERSUS
PHARMACOTHERAPY

50. The debate over psychosocial rehabilitation versus
pharmacotherapy is still a controversial subject.
Pharmacotherapy is important, there is no doubt about that
but in addition to the medical field, rehabilitation has shown
significance in treatment. Psychosocial rehabilitation is a
holistic approach that places the person, not the illness, at the
centre of all interventions (Baron, 2000). Psychosocial
Rehabilitation is a healthy alternative or combination to
pharmacotherapy. Pharmacotherapy and psychosocial
rehabilitation are inseparable; they are two sides of the same
coin (Kopelowicz & Liberman, 2003).
Both have different approaches and for better understanding
the difference between them is listed below in the next slide
in a tabular form.

51. PHARMACOTHERAPY
PSYCHOSOCIAL REHABILITATION
It focuses on the removal of disease
symptoms by diagnosis and
prescription of drugs.
It focuses on the person with the
mental illness as opposed to the
diagnosis of the mental illness.
Focuses on symptom relief and
stabilisation of current condition.
Focuses on recovery process.
It suggests short-term treatment by
medication
long-term treatment focusing on
increasing social status,occupational
roles, and independence within the
community.
Does not prescribe community
integration for treatment
Facilitates for potential supports
within the community as an
alternative to hospitalization.

52. PSYCHOSOCIAL
REHABILITATION OF
PSYCHIATRIC PATIENTS IN
INDIA

53. Current status of psychosocial rehabilitation in India
• Rehabilitation in India is still in its infancy. Although, a
rehabilitation sub program aimed at treating and maintaining
psychiatric patients in the community, was envisaged in the
National Mental Health Program. It could not be implemented
due to variety of a reason (Srinivasa Murthy, 2004). At the
governmental level, policy makers have been unable to
devote serious attention to the development of rehabilitation
services for the chronic mentally ill primarily due to economic
constraints.
The current status of rehabilitation services of our country as
assessed by the national Human Right Commission project
report on Quality Assurance in mental health (1999), is as
follows:

54. Structure
• Number of psychiatrist, social workers, occupational
therapists and even psychiatric nurses in developing countries
can be totally unacceptable by standards elsewhere in the
developed world. For instance, India and Australia have
roughly same number of qualified psychiatrists while the
population of India is about more than 1000 million, while
Australia has about 20 million people, Indonesia until recently
had 1 occupational therapist for 190 million people.
• About 36% of government mental hospitals have a separate
facility for vocational training.
• There are neglected sheltered workshops in the government
hospitals.

55. • Occupational therapy section is present in 63.9% of hospital.
However, untrained personnel in an ad hoc carried out these
activities. Further in 61% of the centers it was noticed that
only a selected number of patients were attending these
activities.
• Awareness among staff in psychiatric hospitals regarding the
principals of rehabilitation is poor.
Day care centres
• Such facilities have started to develop in some hospitals while
7 (19.44%) of the hospital provide day services. The centers
providing day care are NIMHANS, Bengaluru, Mental Health
Centre, Thiruvananthapuram , KIMH, and Chennai.
• 41.66% of centers reported regular production even though
only 36.1% has separate vocational facilities.

56. Rehabilitation wards
• About 8.33 of government psychiatric hospitals have
rehabilitation wards
• There is an interesting experiment being carried at NIMHANS
where the nursing staff has been entirely withdrawn from a
chronic ward and the patients are entirely in charge of the
ward.
Halfway homes
• The half way homes concept has taken root in a few states like
Karnatka, Tamil nadu and Kerala. Such facilities are usually
managed by NGO’S. 87.8% of the mental health centers don’t
have these type of community care facilities in their vicinity.

57. • There are no separate facilities for occupational therapy and
rehabilitation for children in 95% of the hospitals.
Programs
• In 53.65% of the hospitals there are no organized programs
for rehabilitation.
• Combined programs for male and female are present in
5.55%.
• Separate rehabilitation programs for males and females are
present in 33.33%.
• Programs only for males in 2.77% and only for female’s
in2.77%.
• Most hospitals cater predominantly to psychotics.
• 19.44% of the centres ensures employment placement
outside the hospital i.e. NIMHANS.
• 25% of mental health centres paid incentives to the patients.

58. Volunteers and community participation
• Only 25 (67.6%) of mental health centres involve volunteers.
• The family’s role as a partner in care is not utilized in 95% of
the mental hospitals.
National level programs and policies
• Initiatives from the Ministries of Health and Family Welfare,
Government of India
The ministries of health and family welfare have been trying
hard to provide social security and welfare to people with
psychological and behavioural disorders and disabilities. Some
welfare schemes and policies have been implemented by the
central government to strengthen the psychosocial
rehabilitation in the country. After the independence several
legislations and acts have come up to protect the rights and
security of chronic mentally ill people and people who have
any kind of disability, physical and/or mental .

59. Initiatives from the Ministry of Social Justice and
Empowerment, Government of India
•
•
•
•
ministry of social justice and empowerment, Govt of India The
has taken the following schemes and programmes for the
welfare of the people with disability and mental disorders :
National award for the empowerment of persons with
disabilities, persons with any form of physical and
psychological disability and mental illness who have done
commendable tasks in their respective areas, are felicitated
and rewarded.
Financial assistance to the disabled people willing to set up
own entrepreneurs through national handicapped finance and
development corporation (NHFDC) in concessional rates.
Declaration of “national policy for persons with disabilities”
Providing incentives to employers in private sectors for
providing employment to the persons with disabilities.

60. • District rehabilitation centre (DRC) project (1985)
The district rehabilitation centre scheme was implemented to
cater the comprehensive rehabilitation services to the people
with disability who stay in remote and rural areas of the
country. This programme was planned in collaboration with
the national institute of disability and rehabilitation research
(NIDRR), Washington, U.S.A. A specific monitoring and
evaluating authority namely central administrative and coordination unit (CACU) has been set up for looking after the
activities of district rehabilitation centre. At present, 11 DRCs
have been operational in 10 states in India.
• The rehabilitation council of India (RCI)
The RCI was established in the year 1986 to monitor and
supervise the training of personnel related to the
rehabilitation of people with physical and psychological
disabilities, disorders and impairments.

61. It is a statutory body which work under the direct supervision
of parliament of India and has the twin responsibility of
standardising and regulating the training of personnel and
professional in the field of rehabilitation and special
education. It also promotes research activities to serve the
disabled in a better fashion. As per provisions of RCI Act prior
approval of RCI is mandatory for all universities, institutions or
organisations- government or non-government to start any
training course in the field of rehabilitation and special
education.
• The National Trust
The national trust is a statutory body which works under the
jurisdiction of ministry of social justice and empowerment,
Government of India and set up under the National Trust for
the welfare of persons with Autism, Cerebral Palsy, Mental
Retardation and Multiple Disabilities Act (Act 44in 1999). It
initiates and supervises welfare programs for the disabled .

62. The National Mental Health Programme (NMHP)
The NMHP was taken up by Government of India in the
year 1982 to address the mental health related needs of
the people as well as to provide rehabilitation and
aftercare of the persons with mental and behavioural
disorders. It’s a comprehensive mental health
programme which not only provides therapeutic and
rehabilitative services to the mentally ill persons but also
to promote the concept of positive mental health.
Objectives:
• Prevention and treatment of mental and neurological
disorders and their associated disabilities.
• Use of mental health technology to improve general
health services.
• Application of mental health principles in national
development to improve quality of life

63. • To ensure availability and accessibility of minimum mental
health care for all in the foreseeable future, particularly to the
most vulnerable and under privileged sections of population.
• To encourage application of mental health knowledge to
general health care and social development.
• To promote community participation in mental health services
development and to stimulate efforts towards self-help in the
community.
Strategies:
• Integration of mental health with primary health care.
• Provision of tertiary care institutions for treatment of mental
disorders.
• Eradicating stigmatisation of mentally ill patients and
protecting their rights through regulatory institutions like the
Central Mental Health Authority and State Mental Health
Authority

64. District Mental Health Programme (DMHP)
The DMHP was launched with a community based approach
under the NMHP in the year 1996-97.
•
•
•
•
Objectives:
Training programme for all workers in the mental health team
at the identified nodal institute in the state.
Public education in mental health to increase awareness and
reduce stigma.
Providing OPD and indoor service for early detection and
treatment of mental illness.
Providing valuable data and experience at the level of
community to the state and centre for future planning,
improvement in service and research.

65. Rights of the disabled who are mentally ill
• The Mental Health Act, 1987
Under the Mental Health Act, 1987 mentally ill persons are
entitled to the treatment as in patient or outpatient in
government hospitals, voluntary discharge, protection and
management of property under law, govt. Servant who are
mentally ill are entitled to pay, pension, gratuity and other
allowance, etc.
• Income Tax Exemptions for persons with disability and
families
There are special tax concessions in the Income Tax Act for
disabled persons. Section 80 U allows an exception of Rupees
40,000 from the income of the assesses with disability.

66. To avail of this concession a disability certificate issued by a
physician working in a government hospital has to be annexed
with the tax assessment form. Section 80 DD allows
deductions of Rupees 50,000 to a parent or relative upon
whom the disabled is dependent for maintenance, which
includes medical treatment of the disabled person
• Exemptions on donations
Deductions are allowed to persons making donations to
registered trusts and societies doing work for the
handicapped. The relevant sections are 80G and 80GGA.
Under Section 80G deduction from Income is allowed at 50
percent of the amount donated to the eligible institution. The
amount on which deduction is claimed under the section,
however, cannot exceed 10 percent of the gross total income
exemptions. This is only in respect of certain specific projects
for research, development etc. Deductions in respect of
donations may be claimed by all assesses, i.e., individuals,
companies etc.

67. • Exemptions in Custom Duty
Certain other special goods imported by a disabled or
disabled person for his personal use are exempt from duty.
(Notification No. 20/99 Customs S.No. 278).
• Exemptions in Excise Duty
The Central Government exempts all goods manufactured by
an institution which:
 Is primarily engaged in the rehabilitation of physically or
mentally handicapped persons.
 Employs primarily, physically or mentally handicapped
persons for its manufacturing activity, is receiving financial
assistance from the Govt. of India, Ministry of Social Welfare
for such rehabilitation.

68. • Facilities in travelling
Indian railway provides facility of free travelling of mentally ill
person for treatment. Central and state government provides
facilities in travelling.
Acts/legislations protecting rights of mentally ill and
disabled people in India
• The persons with Disabilities (Equal Opportunities, Protection
of Rights and Full Participation) Act, 1995
• The Mental Health Act, 1987
• Rehabilitation Council Act, 1992
• The Narcotic Drugs And Psychotropic Substances Act (NDPSA),
1985

69. Major Rehabilitation centres in India
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•
•
•
•
•
•
•
•
Some of the major voluntary/ non-governmental
organisations/ autonomous organisations in India working in
psychiatric and other disability rehabilitation fields are:
National institute of mental health and neurosciences
(NIMHANS),Bangalore, Karnataka
Deepsikha institute, Ranchi, Jharkhand
Care India
Sevak, Kolkata, West Bengal
Child in need institute (CINI), Kolkata, West Bengal
Samarpan care awareness and rehabilitation centre, Indore,
Madhya Pradesh
Ashadeep, Guwahati, Assam (working for psychosocial
rehabilitation for mentally ill)
Antara, centre for rehabilitation of mentally ill and substance
addicted person, Kolkata, West Bengal
CAIM, Deaddiction and rehabilitation centre, Bangalore.

70. • St. Joseph rehabilitation centre and relief services, Kolkata,
West Bengal; treatment centre for chemically dependent and
mentally disturbed.
• Thakur Hari Prashad institute of research and rehabilitation,
for mentally handicapped, Andhra Pradesh
• V.D. Indian society for mentally retarded, Malad (W), Mumbai,
Maharashtra
• Schizophrenia research foundation (SCARF), Chennai, Tamil
Nadu.
• Nav bharat jagriti Kendra, Ranchi and Hazaribagh, Jharkhand
• The association for the welfare of persons with a mental
handicap in Maharashtra (A.W.M.H. Male)
• Mukta, Mumbai, works for employment and income
generation
• GRIP- group of rehabilitation, intervention and prevention,
Bandra, Mumbai, Maharashtra
• Chetna, Lucknow, Uttar Pradesh

71. • Richmond foundation, Bangalore, Karnataka
• Shraddha (rehabilitation foundation for mentally ill roadside
destitute), Borivali, Mumbai
• Param mitra sadan, brother of charity, Kanke, Ranchi (is a half
way home)
• Alokendu bodh niketan, Kankurgachhi, Kolkata, West Bengal
• National institute of mentally handicapped (NIMH),
Secunderabad, Andhra Pradesh
• National institute of rehabilitation training and research
(NIRTAR), Cuttack, Orissa
• National institute for empowerment of persons with multiple
disabilities (NIEPMD), Chennai, Tamil Nadu
• Central Institute of Psychiatry (CIP)

72. Ranchi Institute of Neuro-Psychiatry and Allied Sciences
(RINPAS) and psychosocial rehabilitation.
• The history of this institute dates back to 1795 A.D. when the
Lunatic Asylum was established in Munghyr. Later it was
shifted to Patna in 1821 and then to the current location
Kanke, Ranchi and was renamed as Indian Mental Hospital
(IMH) in 1925. After Independence this hospital came under
State Govt. of Bihar in 1958 and the name of IMH was
changed to Ranchi Mansik Arogyashala (RMA). On 10th
January 1998 the name of RMA was changed to Ranchi
Institute of Neuro-Psychiatry & Allied Sciences (RINPAS).
• Currently RINPAS is showing an upward trend in the care of
mentally deranged people by providing quality assurance,
rehabilitation, community outreach programme, teaching and
research activities.

73. • The institute is running a full fledged occupational therapy
and rehabilitation unit offering comprehensive vocational
training to in-patients. There are two separate occupational
units for male and female section.
• At present both male and female occupational therapy units
are equipped with machines and instruments as well as skilled
and trained occupational therapy professionals. Both the units
have been provided with all sorts of modern gazettes and
equipments necessary for providing occupational skills
development programme and rehabilitation to the patients’
with long term mental illness.
• A token economy system operates where the patients who
work in the OT sections earn tokens according to their level of
skill and performance. Patients who just come and sit in O.T.
Section are are also given tokens accordingly, to motivate and
inculcate in them the habit to work. Patients exchange the
tokens earned for snacks and tea from the canteen and rest
savings they take home on discharge.

74. • Currently the institute is running four satellite clinics at Jonha,
Khunti, Saraikela Kharsaon and Hazaribagh. The institute is
sending medical team comprising of psychiatrists,
paramedical staff and students to these outreach community
centres every Tuesday of a month. The institute is helped by
NGO’s like Nav Bharat Jagriti Kendra & Sanjeevini Gram Trust
for these community outreach programs.

75. FUTURE DIRECTION

76. • Psychosocial Rehabilitation services should be accessible,
equitable and affordable.
• Government should downsize large psychiatric hospitals.
More open ward treatment facilities must be created.
• Human resources for psychosocial rehabilitation must be
systematically enhanced through both short-term and longterm strategies.
• There should be a national data base of services and human
resources available for psychosocial rehabilitation in the
country and this should be periodically updated.
• Psychosocial rehabilitation must be converged with the
social, education, labour and legal sectors. Translational
research must be encouraged in all areas.
• Law review and reform needs to occur periodically. They must
emphasise community care, rehabilitation and aftercare.

77. • Limitations imposed on mentally ill receiving rehabilitation in
the area of insurance should be rectified.
• The rehabilitation of vulnerable groups like children, elderly,
and women who are subject to domestic violence should
receive priority attention.
• There is a need to design outcome studies regarding the
effectiveness of rehabilitation program and also it is needed
to recognize the interaction between drugs and
environmental therapy effects especially in case of ward
managements.
• Patients and family members will become more effective as
advocates for needed services and partners in treatment,
planning and implementation. It is necessary to encourage
NGO to start half way homes.

78. The family’s participation and involvement through regular
contact with the half way home staff should be encouraged to
make community adjustment easier.
• There is an urgent need for more day care centers that can
provide the much-needed respite for the family as well as
make the individual patient feel less stigmatized and more
valued.

79. CONCLUSION

80. Psychosocial Rehabilitation exhibits principles of hope, change
and recovery for Persons with severe and persistent mental
illness. Effective mental health service providers should
facilitate change through the recovery-oriented theory.
Recovery is individualized and person centred, placing the
person at the core of all interventions with the goal of
rehabilitating and re-integrating the individual to active
community life. For successful rehabilitation, co-operation
and collaboration of health care personnel, patients and their
family members, opinion leaders, policy makers and various
agencies are indispensable. Then only we can hopefully
address the rehabilitation of psychiatric patients in a more
meaningful manner and make them more meaningful citizens
of our country.

81. For a successful outcome it is very essential to catch
the hint for psychosocial rehabilitation at an early
stage.
How many times it thundered
before Franklin took the hint!
How many apples fell on
Newton’s head before he took the
hint! Nature is always hinting at
us. It hints over and over again.
And suddenly we take the hint.
—Robert Frost

83. WHERE THERE IS NO
HOPE THERE IS NO
RECOVERY
THANK YOU