Psychiatric rehabilitation: general issues

Eur Psychiatry 1996;1I(Suppl 2):39s-50s

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e Elsevier. Paris

Psychiatric rehabilitation: general issues H Hafner Central Institute of Mental Health, PO Box 12 21 20. D-68072 Mannheim; Germany

Summary - Rehabilitation aims at avoiding unfavourable consequences of a disorder and its care and at training and improving impaired and compensatory skills. The needs of the main diagnostic groups with resulting cognitive or social impairments, namely mental retardation. infantile autism, chronic depression, severe psychoneurosis, substance abuse. schizophrenia, and dementia in old age. have specific aspects. An increased need for rehabilitation was prompted by the worldwide movement of deinstitutionalisation, which hit above all the socially most vulnerable schizophrenics. The instruments and methods of rehabilitation for the socially disabled mentally ill go far beyond the sphere of psychiatry. Individualised rehabilitation must be in mutual interaction with the social and occupational environment. The socially disabled individual is. for example, dependent upon awareness and acceptance in the community, upon financial and social support or upon the availability of a job. In the case of persisting deficits, supportive measures at different levels are needed to compensate or to minimize severe consequences of impairments. Their approach is by the social environment with the objective to grant the optimum quality of life combined with a minimum loss of independence. The great variety of measures often required at the same time must be based on a network of services and their purposeful coordination. Psychiatric rehabilitation requires a functioning social system and, in times of scarce resources, political priorities. psychiatric rehabilitation' needs for rehabilitation' training of Impaired skills' compensation of deficits' rehabllltatioD techniques , socially disabled' social skills training 'Individualised rehabilitation' rehabilitation In schizophrenia

INTRODUCTION

The objective of rehabilitation is to enable the patients after their recovery to reacquire their former social and occupational status and to help the disabled and handicapped to achieve the maximum in health. work competence. occupational and social integration, and quality of life in general, if necessary by providing compensation (income, accommodation, supervised workshops, etc). This vision of rehabilitation reaches far beyond medical intervention into the whole complex living situation of the disabled person. For this very reason, the importance of rehabilitation is nowhere nearly as great as in the mental health field. HISTORICAL ASPECTS

Early milestones in the long history of psychiatric rehabilitation were the medieval asylums which provided care for the chronically mentally ill. In the 16th century, for example, Duke Philipp of

Hesse established psychiatric hospitals in the monasteries that had been abandoned during the Protestant reformation. Offering safety, food and shelter in rural surroundings with a large range of occupations as farm and house helps, they possibly provided the patients with the optimum quality of life in the tough conditions of the middle ages. The principles of care of the psychiatric hospitals, however, remained essentially unchanged until the 20th century. As long as the situation of the ill people in residential care was much better there than in their own families, the hospital was a real advantage. In the course of time this relationship has been completely reversed in the European countries. A fundamental change also took place concerning treatment: some of the disorders that had been regarded as incurable had become accessible to effective intervention, eg, paralytic dementia to causal treatment, many others such as affective psychoses and schizophrenia to symptomatic and preventive treatment.

40s

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RlIle/1oo.000 300

250

..,

200 fRG (old) 170

•........... " ,

·······,oIIt-c:~•••••••••••

150-

"

... _----

.

~;.~;..;~.;:.~ . - - - - - - - - - •••••

111,4 107,5

100

110 94

50

o

I

1964

66

68

70

72

74

76

78

80

82

84

B6

as

90

1992

y"ar

FIg 1. Occupied beds in psychiatric hospitals and units (England, 1965.1992; Denmark. 1970-1991; USA. 1970-1988; FRO. 19731990). Sources: GB: DHSS. London; OK: The Danish National Psychiatric Register; USA: NIMH; FRO: Federal Ministry of Health.

DEINSTITUTIONALISATION

Harsh criticism of the living conditions in large psychiatric hospitals. the findings of Wing and Brown (1970) on institutionalism as a consequence of social deprivation, and the hope of politicians to save money by reducing the number of psychiatric beds prompted a wave of deinstitutionalisation. In countries with high initial values this took a dramatic tum (fig 1). The occupancy of psychiatric beds has in the meantime reached a similar level of approximately 1.0 per 1.000 in many countries of the western world despite considerable differences at the outset. The end of this development cannot yet be predicted. The decisive factors are above all the reduced length of hospital stays and the discharge of long-stay patients. These extensive changes can be illustrated by the decreasinglengths of the first hospital stay of schizophrenic patients since 1900. Using twelve fairly representative first admission studies from four countries covering the period from the tum of the century until the present time by five-year periods it can be demonstrated that the proportion of patients discharged within one year has increased from approximately25% to nearly 100% (fig 2).

FIELDS OF REHABILITATION FOLLOWING DEINSTITUTIONALISATION

The deinstitutionalisation process is carried out only in some cases under careful evaluation. ego Priem and Claybury Hospitals in London (Leff, 1993). But it represents the most crucial field of psychiatric rehabilitation of our time: the reintegration into the community of socially disabled patients discharged after long periods of hospitalisation. There are various countries where compulsory mass discharges led to poverty and homelessness (Torrey. 1988). This demonstrated that a great number of these patients were not only impaired in leading their own economically and socially independent life, but were also lacking the essential familial, social and financial resources. Psychiatric rehabilitation therefore refers not only to the restoration of individual skills but also to compensatory and supportive means if the patient can no longer cope with essential living conditions on his own. The rehabilitation of disabled persons in the community is therefore dependent upon a system of financial and social support . In countries like the USA where such a system is practically non existent, more and more

Psychiatric rehabilitation: general issues ~ Mannheim 4) (1987-91)

Denmark 3) (1981)

%

Mannheim 2) (1980-81) Mannheim 2) (1973-78)

.............

100 90

USA

1) (1948-50)

USA

1) (1940-41)

60

USA USA

1) (1936-45) 1) (1943-44)

50

USA

1) (1926-35)

40

USA UK USA

1) 1) (1909-11) 1) (1900-01)

80 70

o

2

years

3

4

5

Fig 2. Percentage of first admissions for schizophrenia discharged within 5 years. I) Brown (1960); 2) Case register, Medical Documentation. CIMH; 3) University of Aarthus, Dept. of Psychiatric Demography; 4) Medical Documentation Centre. CIMH.

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To what extent these high principles have been implemented in legal systems and in the practical life of the states of the European Community (EC), cannot be referred to in detail. So far, the EC's activities have been focused mainly on pilot and research programmes, investigations and public discussions. With respect to the similarity of the cultural, social and economic systems and of the standard of living it seems justified to treat general aspects of psychiatric rehabilitation for the European countries as a whole. In this context some common problems will emerge, such as the discrimination of socially disabled mental patients as against other groups of disabled persons. This is due not only to the more recent attitude of acceptance but also to the greater need of complementary and supportive services. Moreover, unlike somatically ill and handicapped people, mental patients have long been unable to express effectively their interests before the public and the political authorities. In the meantime, it has become more and more evident that the confidence of the socially disabled has also increased. In several European countries. associations of relatives and of former patients have taken the political representation of interests into their own hands.

Goals and feasibility of psychiatric rehabilitation demands have been made that the safe and sufficient life in the psychiatric hospital should be preferred to "homelessness" or "street walking". Thus, rehabilitation would again be placed with the hospital.

Rehabilitation for the socially disabled mentally ill as a problem of priority-setting in social politics Psychiatric rehabilitation needs considerable service transfer from the society. Therefore it is clearly dependent upon policies and legislation to create the necessary legal, financial, and social conditions. Some initiatives have been started to this end in the past. In 1971, the United Nations unanimously passed the "Declaration on the rights of mentally retarded persons". And in 1975, the UN General Assembly passed a "Declaration on the rights of the disabled persons" demanding equal rights for the disabled as for their healthy fellow citizens, irrespective of cause, type and severity of the disablement. At the same time they were granted the right to demand supportive measures enabling them to live in as much independence as possible.

The scope and fields of rehabilitation are concerned, firstly, with congenital or early acquired disability. Preserved skills and abilities must be developed as far as possible and compensational skills must be trained to compensate for persisting deficits that cannot be reduced. Secondly, inpatient rehabilitation of the mentally ill seeks to avoid or diminish the consequences of the disorder, but also of treatment or environmental circumstances during hospitalisation. Thirdly, aftercare and outpatient rehabilitation of mental patients should also help to diminish or eliminate disability as a consequence of the disorder by training impaired skills and by improving compensatory performances. The first and central approach by rehabilitation measures is aimed at the disabled person himself. He must be enabled to look after his personal and occupational situation - work, financial security, social integration and an adequate standard of living - on his own or to attain the highest possible degree of independence. Wherever this is impossible and a considerable level of disabilities or selective impairments leave the patient dependent

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on the help of others, it is the social environment of the disabled person that is approached by rehabilitation measures. Compensatory services, general supportive measures or specific instrumental aids are then, limited to the necessary extent, the goal of rehabilitation. Rehabilitation of congenital or early acquired psychiatric disability Examples of congenital or early acquired disabilities are the many forms of mental retardation and child autism. The bulk of rehabilitation for persons with developmental disorders lies in the hands of special school teachers. The contribution of psychiatry is focusing on the intervention in secondary symptom patterns such as anxiety disorders, obsessional symptoms, eating disorders, psychosis-like disturbances and severe behavioural disorders, eg, physiological hyperarrousal, hypersexuality, repetitive behaviour and fixed habits. On the somatic level a large range of efficient drugs such as lithium, antiandrogenes or psychotropic drugs are available, on the psychological level it is above all methods of behaviour modification that can be employed. Whereas the rehabilitation of individuals with mental retardation aims at best developing practical living skills and avoiding individual harmful behaviour, the rehabilitation of autistic patients focuses on the improvement of social and communication skills. This is accomplished above all by means of non- or low-verbal communication media such as music, dance and picture series with familiar persons and scenes, which can also be used in the form of videos and sound films in order to facilitate social perception and communication. Inpatient rehabilitation of mental disorders and tertiary prevention of social disability As rehabilitation aims at the preservation and rehabilitation of skills at risk it ought to have decisive influence on the organisation and length of inpatient treatment. The fact that long hospital stay can have negative effects on social skills has gradually been accepted starting from the beginning of this century. Apart from social role and status deficits due to social deprivation during lengthy stays in the psychiatric hospital and other residential environments, an additional risk is that of conditioning disabling behaviour patterns such as increasing avoidance behaviour for social anxieties. The therapeutic revolution which essentially

improved the rehabilitation chances of large groups of mental patients, at the same time created a new problem: side effects of neuroleptic drugs. If they reach a high level, they can cause or aggravate motor, cognitive and social impairments (Falloon et al, 1978; Jolley and Hirsch, 1990), depression or dysphoria (Van Putten and May, 1978; Van Putten and Marder, 1985), and negative symptoms (Kane et al, 1986). The tools necessary to avoid these risks are i) the reduced length of hospital stays to what is absolutely necessary, ii) the systematic training of cognitive, social and also physical activities in the clinical treatment phase, and iii) the avoidance of disabling side effects of psychotropic drugs by using the lowest possible (though sufficiently high) dosage. Instruments of clinical rehabilitation tailored to different needs The rehabilitation methods must acknowledge the profiles of the affected skills and at the same time closely correspond to the individual and occupational abilities and competence of the patient. Therefore the clinical rehabilitation services must offer a great variety of training programmes and settings. If clinical rehabilitation is restricted to traditional occupational therapy of pastime quality, it usually contributes only to give the patients a daily schedule and to help them to reduce pathological thoughts. which. however, is not unimportant either. The usual spectrum of clinical rehabilitation facilities is above all indicated for patients with mental dysfunctions such as severe neurosis, schizophrenia and chronic depression. For depressive patients it is of particular importance, in the attempt of overall activation, to support the development of creative skills and to train the cognitive emotional and physical abilities to induce pleasure and to enjoy life. Partially different measures are offered to patients with alcohol or substance abuse. Intensive group therapy programmes together with social and occupational rehabilitation activities, smoothly leading to aftercare are the preconditions for short hospital stays (Ritson, 1993). A continuously growing number of patients needing a specific type of clinical rehabilitation are elderly patients with cognitive impairments and beginning dementia or with chronic depression. For these it is above all basic rehabilitation in the form of physical activation and social communication training that must be offered, if necessary

Psychiatric rehabilitation: general issues

accompanied by the reactivation of their social networks support and the training of daily living skills. The differential efficacy of individual approaches to rehabilitation is still largely unknown, especially concerning the costs. The lack of knowledge in this important area of evaluative research cannot be compensated quickly because there is a great variety of needs, a complexity of approaches to rehabilitation and a diversity of settings that must be taken into account. Aftercare and long-term measures of personal and vocational rehabilitation Inpatient rehabilitation should prepare the patients for their discharge and the subsequent reintegration into work and social environment guaranteeing the continuity necessary for this process . With the patients' discharge, the responsibility for further treatment and rehabilitation is generally transferred from the hospital to extramural services. The programme of these extramural services must be even more closely adapted to the needs and capabilities of the patients. Therefore the careful examination of existing disabilities and of the availability of the necessary extramural services prior to discharge is an essential demand. Strathdee and Thornicroft (1992) developed a set of criteria for the core group of socially disabled chronic mentally ill (table I). From this compilation as well as from community and population studies it clearly emerges that the majority of these are schizophrenics. For this reason we will, in the following, focus on the rehabilitation of schizophrenic patients as an example for which most findings and experiences are available. When should the rehabilitation of schizophrenics start? At what point in the course of the disease should rehabilitation be started? Figure 3 demonstrates on a representative sample of 132 first episodes from our ABC schizophrenia study that the maximum of employment losses occurred already in the prodromal phase prior to the appearance of the first psychotic symptom, whereas rehabilitation measures started only after first hospital admission. In other words, the majority of rehabilitation programmes obviously sets in too late. The early application of these measures, however, is met with great difficulties in schizophrenia because so far a reliable diagnosis of the disorder in its prodromal phase by negative and non-spe-

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Table I. Characteristic features of severely mentally ill with high need for rehabilitation at the level of impairments, disabilities and handicaps. Impairment

Disabilities

Handicaps

Cognitive Inefficient problem Lack of friends Difficulties solving in thinking Unemployment Interference with Slowed learning thought processes Distressing experiences of sight, sound or touch Affective Severe anxiety Unusual. strange and fear beliefs Feelings of Difficulty inadequacy in movements and actions Decreased concentration Loss of energy and drive Reduced ability to solve problems

Behavioural Low rate or constructive actions

Limited 1eisure activities Poor housing and self-care

Carers burden

Source: Strathdee and Thomicroft (1992) .

cific symptoms is hardly possible. We can only hope for an early assessable marker to be discovered. Until then we can only call for rehabilitation measures to be considered for schizophrenic patients as soon as the disorder can be diagnosed with some certainty. This can be done at the beginning of the first psychotic episode, ie, on average about one year before first admission. Approaches to individualised rehabilitation In principle, several approaches to individualised rehabilitation are feasible: - The complex deficits may be due to "basic dysfunctions". The improvement of elementary functions by means of specific training techniques may lead to secondary effects in more complex functions. - Variety and range of dysfunctions, for instance of speech and expression, lack of initiative and emotions, social and cognitive deficits, suggest that rehabilitation measures must use a global approach and train the impaired complex functions in a realistic manner. They may thus at the same time support the development of non-trained functions by means of transfer effects. - Specific improvement of unimpaired functions and skills may further the development of compensatory skills and of better coping techniques .

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patients (%) 100 (N=133)

90 -

eo

First admission

70

60 50 40 30

20

... ........

10

...............s

••••• In rehabllltatlon

o Beginning or

. .......

prodromal prephase

Beginning of psychotic prephase

Imean:8.3 yeara berorellnllldml88lon)

before first Idmlsslon)

6 months after first admlaslon

1 year after first admission

2year8 after first admission

lmean:1.7 y8ar8

Fig 3. Employment in a representative cohort of schizophrenics at 6 cross-sectional assessments from first sign of mental disorder until 2 years after first admission (retrospectively until first admission, prospectively thereafter).

The progress in neuropsychology and the increasing interest in an explanatory model of developmental disorders of the brain have revived the hope for intervention strategies with special focus on elementary neuropsychological functions (Jaeger et al, 1992; Jaeger and Douglas,1992). To this day a persistent reduction of social and cognitive deficits through the exclusive training of elementary functions has not been reliably proven (Olbrich and Mussgay, 1990). Therefore it is quite understandable that profound effects on social and cognitive impairments of schizophrenics cannot be found either. Computer dialogue programmes for attention, concentration and cognitive skills training have recently been developed, which enable the patient not only to practice self-control and reinforcement exercises but also to continue his training programme on his own. They are accepted by the patients with astonishing approval (Olbrich, 1994). Hopefully they will produce some effects in the long run.

The oldest training methods for the reinforcement of social behaviour were the token-economy programmes. Their successful implementation was largely based on synergic effects on the behaviour of the personnel in the treatment institutions. However, generalisation usually failed because after discharge it was hardly possible to offer the patients further reinforcement or motivation. The token economy programmes were followed by the social - skills - training strategies (Siegel and Spivack, 1976; Hersen and Bellack, 1976; Wallace et al, 1980; Liberman et al, 1984). Their approach focuses mainly on the deficits in social competence and coping with everyday life. The most advanced programme is the "SST' by Liberman and Wallace (1990) (table II). It is based on the simulation of social interactions in role plays as well as on the direct training of social behaviour and coping strategies. This comprehensive programme of ten modules is meant to train not only complex practical skills

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Psychiatric rehabilitation: general issues Table IL Modules of the social skills training programme by Liberman and Wallace (1990). Itl flelds

Step ofapplication Introduction to module

Conversation skills Yocational rehabilitation Dwelling and home maintenance Medication self-management Leisure-time activities and recreation Self-care and personal hygiene Use of public transport Preparation of meals Money management Dealing with authorities; use of community services

Solution of resource management problems

Fig 4. Schematic representation of the integrated psychological therapy programme (IPT) for cognitive. social and communication skills . Source : Brenner et al, 1987.

but also attention, information processing and problem solving behaviour, ie, to act retrogradely from training in everyday life to improving elementary functions. Beyond the specific impairments of schizophrenics it promotes a number of compensatory skills such as problem solving and independent living skills and the use of social and financial resources. The efficacy of the programme was confirmed by a controlled study, but so far the confirmation of generalised and persisting effects is yet to follow. This is due to methodological problems of the complex approach which the authors have not yet been able to solve (Liberman and Wallace, 1990). A combined approach on the basis of experimental psychological investigations, which is meant to train cognitive processes on an elemen-

] -

Solution of outcome problems In vivo exercises

Homework exercises Reinforcement exercises

COCJIl.nvt DIPPERZH'I'IATIOH

Conducted in treatment setting

Skills practice

J

Conducted in natural environment

tary level and to improve social skills on a more complex level, is the Integrated Psychological Therapy programme (IPT) developed at the Central Institute of Mental Health in Mannheim and further differentiated in Bern by Brenner et al (1987) (fig 4). It comprises five subprogrammes which are to be performed successively with increasing parts of complex social behaviour training. It has been evaluated several times (see reviews by Brenner, 1986; Mussgay and Olbrich, 1988; Roder and Brenner, 1990). The results show mainly significant effects in comparison with controls but are not fully consistent in substance. For the practical implementation of rehabilitation measures it seems most useful and promising to train the impaired cognitive and social behaviour in close-to-natural settings and soon to generalise on the living situation of the patient, always taking into account the relapse risk that can be associated with social overstimulation. Which of the training strategies will lead to optimum effects in the long run cannot yet be told definitely. Methods for the improvement of coping behaviour are expressly based on skills not affected by the disorder. One of the primary goals is the prevention of relapse, which can be achieved because many patients who have long been afflicted by the disorder can recognise reasons for relapse themselves. In a retrospective study (Thurm-Mussgay and Hafner, 1990) of a cohort of 37 schizophrenic patients with nine years' mean duration of the disorder, interpersonal conflicts and intensive emotions in close relationships were referred to as the most frequent causes of relapse representing 65%. And in the patients' opinion the intensity rather than the quality of emotions was the decisive factor.

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Table In. Mastery of symptoms.

Coping strategy

n

% ofpatients

Help seeking Emotional coping Increased medication Change of behaviour No influence possible No prodromal symptoms perceived

17

10 6 3 6

46.0 27.0 16.2 8.1 16.2 27.0

10

n = 37 patients; mean duration of illness 9 years. Source: Thurm and Hafner, 1987.

Table IV. Rehabilitation and care for chronic mental patients.

Level ofneeds "need for care"

Provision ofcare

I Accommodation

2

3 4

5

Supportive homes, group homes. supervised apartments etc. I Drug therapy and prevention of relapse 2 Psychological training programme for deficits Psychiatric treatment and compensatory skill 3 Psychotherapy: development of individual coping strategies. family management Leisure-time activities Patient clubs, lay initiatives Social integration Community and social psychiatric services. family and patient initiatives Vocational rehabilitation Training on the job. psychological aid at work, workshops for the disabled

Source: Hafner, 1988.

The first step of this strategy is to improve the recognition of relevant precipitating factors and prodromals of relapse. The second step consists in the attempt to discover coping strategies which the patient himself has applied successfully in the past. They can provide important clues for the improvement of available and the creation of new coping strategies (table III). Moreover, the compensation of lasting deficits and the management of chronic symptoms is an aim of rehabilitation which may lead to better social functioning.

Supportive measures of rehabilitation for the chronically disabled Despite all efforts of clinical rehabilitation there remains approximately 40% of patients with

severe social disabilities which possibly cannot be eliminated, neither by the existing repertoire of training measures nor by improving compensatory skills. This group of socially disabled patients who are described as particularly vulnerable concerning their high risk to fall by the social wayside and to be reduced to poverty (Wing et al, 1992; Strathdee and Thornicroft, 1992), must be offered supportive measures specifically adapted to their handicaps. The list of services that are attributed to the levels of need in table IV makes it again evident that the range of necessary supportive measures reaches far beyond the sphere of psychiatry. This vulnerable group of mentally ill patients and their social development are clearly dependent upon the system of social security and the living conditions in their communities. In this context the APA Task Force Report states that "aid for the homeless mentally ill must begin with provisions for meeting their basic needs: food, clothing and shelter" (Talbott and Lamb, 1984). These plain words show that rehabilitation of psychiatric patients is dependent on the provision of basic conditions. If a resourceful system of social security is able and ready to offer alternative institutions for the rehabilitation of mentally ill, then the services listed in table IV should be provided. To give an example: from 1975 until the present time Mannheim, a city with a population of about 300,000, established five psychiatric homes offering 150 places for the socially disabled mentally ill. eight supervised apartments with 66 places and 123 places in sheltered workshops. Consultation and coordination is given by the department of community psychiatry of the Central Institute of Mental Health. Coordination is of central importance because a great number of mostly independent institutions with different service ranges and capacities must combine their efforts in order to knot the net of community care for the socially disabled and to implement the global concept of rehabilitation. For this very reason the coordination of the necessary institutions and services is also necessary for the rehabilitation of each individual patient. A patient stream analysis (fig 5) shows the complexity of the patterns of care for mental patients by depicting the utilization of only three categories of services by a cohort of 143 schizophrenic patients assessed every fortnight across 2 In months and after 36 months (Hafner and an der Heiden, 1982). To combine these complex services to provide a reasonable concept of care, the position of "case manager" has been created in several countries, eg, Great Britain and USA (Beeson, 1983; Johansen,

Psychiatric rehabilitation: general issues TYPEOFCAAE INPATlCNT

SHaTER HOMES

OUTJlATlENT

NOAfTERCARE

z

3

, 5

Fig S. Analysis of patient streams. Source: Hafner and an der Heiden (1982).

1983; Bachrach et al, 1987). In Germany, social psychiatric services were established having the same functions (Rossler et al, 1993). In a study evaluating this new institution, Rossler et al from our Mannheim Institute were able to show that the activities of social psychiatric services across a two-year period actually resulted in a generally improved social adaptation of socially disabled mental patients. High intensity of contact, however, ie, several times per week, was associated with a reverse effect, a decrease, though not significant, in social adaptation. It should be considered that this may have been the negative result of social overstimulation. The reciprocity of individual needs and social environment in the rehabilitation of the socially disabled mentally ill The reintegration of socially disabled patients is also dependent upon the availability of desired social roles and on the mutuality of social interactions. In other words, it requires acceptance in

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family, neighbourhood, and community and the possibility to take up important social roles, for example finding a job. This, however, presently meets with severe difficulties all over Europe. What can we in our position as psychiatrists do to provide the external conditions for a successful implementation of our rehabilitation programmes? Our means are limited towards opening up chances for employments. One possible way is to cooperate with as many employers as possible about job reentry training. The so-called Starthilfeprojekt (starting aid project) of the Central Institute of Mental Health, for example, provided 51 patients discharged from the Institute with trial work places in a total of 47 different shops and factories during the first nine months of 1993. In this short period no less than one third (17) were given an ordinary job, six. of them by returning to their former working place. The others are either still having trial jobs, participate in long-term rehabilitation programmes, or - in the case of negative results were taken up in sheltered workshops . Nevertheless, these figures cannot conceal that the high unemployment rate with its extraordinary impact on the mentally ill (in our own study about 60% of the schizophrenic patients with an average of 5 years since first admission were without job after discharge, see Hafner and an der Heiden, 1986) and the poor economic situation of many communities prevents a strong support for the disabled and compells to set up priorities. Therefore it is necessary to represent the interests of particularly vulnerable groups of mentally ill patients and at the same time to check the possibilities of establishing rehabilitation services without raising the costs. This includes the transfer of means from hospital budgets set free by deinstitutionalisation to the community-centred rehabilitation of psychiatric patients, as it was done in connection with the closure of Friem and Claybury Hospitals in London (Beecham and Knapp, 1992). The role of the family in the rehabilitation of chronic mental patients A factor that must also be addressed in this context is the role of the family, which is for younger patients mainly the parent family and only in a small proportion of patients the partner family. The results by Vaughn and Leff (1976) on the expressed emotion paradigm already suggested the investigation of a causal association between family atmosphere and relapse risk by means of intervention studies (table V) (Goldstein et al, 1978; Leff et al, 1985; Falloon et aI, 1982; 1985;

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Table V. Relapse rates in intervention studies focused on the association with expressed emotion.

Study

Relapse rates 24 months

Leff et al, 1985 Family therapy Conventional treatment Falloon et al, 1985 Family therapy Individual therapy Hogarty et al. 1986 Family therapy Training of social skills Combined intervention Control group Tarrier et al, 1988a,b HighEE Family therapy Conventional treatment LowEE Conventional treatment

* Results only in percent; no actual

2110 7/ 9

20% 78%

3/18 14/18

17% 83% 32%* 42% 25% 66%

8/24 17/29

33% 59%

6118

33%

figures given (Hogarty et al,

1987). EE: expressed emotion.

Hogarty et al, 1986; 1987; Tarrier et al, 1988). Despite some differences the programmes have several aspects in common: they all contain a psycho-educational focus describing the nature of the disorder, its symptomatology, course and treatment. The behavioural analysis of family functions, partly supported by the Camberwell Family Interview (Vaughn and Leff, 1976; Tarrier et al, 1988b), serves as the basis for the training of communication skills and interpersonal problem solving techniques. Moreover, behavioural strategies are provided for the solution of specific problems. Controlled evaluation studies showed that the psycho-educational family therapy yielded significantly better results than other therapies concerning relapse rates and social functioning for patients from high expressed emotion (EE) families with continuous neuroleptic medication. For patients with neuroleptic maintenance therapy from low EE families no significant effects could be found, which is, however, of minor importance in view of the extremely low relapse rates in this group of patients (Leff, 1991). These findings emphasise that a minimum programme of psycho-educational family therapy for socially disabled schizophrenic patients living in high EE families or similar environment is an essential part of comprehensive rehabilitation.

Perspectives of rehabilitation Finally, the temporal aspect of rehabilitation,

which is determined by the course of disablement, is of major importance. The longitudinal studies on the clinical course that are affected by selective influences difficult to control (Bleuler, 1972; Ciompi and Muller, 1976; Huber et al, 1979; Harding et al, 1987; Marneros and Tsuang, 1990) suggest that at least some improvement of the psychotic symptomatology and of social competence after more than 20 years' duration of the disorder can be expected. The findings by an der Heiden et al (1995) from our Institute, who conducted a careful follow-up study of a representative first-admission sample of schizophrenic patients 14 to 15 years later, provide evidence that neither the group means of symptomatology nor of severity and profile of social disability have changed significantly over this long period. The onset of schizophrenia is predominantly very early and leads to functional impairments and social status deficits already in the prodromal phase prior to first admission (Hafner et al, 1994). During the long-term course there are irregularly occurring psychotic episodes and wide variations in the unspecific and negative symptomatology accompanied by functional impairments and social disabilities. Nevertheless the group trends for symptomatology and social dimensions persist at a comparatively stable level after remission from the lII'St psychotic episode (Biehl et al, 1986; Hafner et al,1986). As social disabilities and status deficits often have a lifelong persistence, rehabilitation programmes should not only start as early as possible but should also be continued over the whole period in need, which sometimes means rehabilitative measures for a lifetime. In the case of persisting deficits and severe social or financial problems, it is essential to provide permanent support without causing unnecessary loss of independence. The rehabilitation of socially disabled psychiatric patients is an expensive matter with regard to the necessary personal and financial resources, but it is indispensible for the quality of life of many socially disabled or vulnerable mental patients. It is therefore one of the major ethical tasks of humanitarian societies.

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