What is Psychosocial Rehabilitation

In 1985, the International Association of Psychosocial Rehabilitation Services (IAPRS) published the following definition of psychosocial rehabilitation as

The process of facilitating an individual's restoration to an optimal level of independent functioning in the community .... While the nature of the process and the methods used differ in different settings, psychosocial rehabilitation invariably encourages persons to participate actively with others in the attainment of mental health and social competence goals. In many settings, participants are called members. The process emphasises the wholeness and wellness of the individual and seeks a comprehensive approach to the provision of vocational, residential, social/recreational, educational and personal adjustment services.' (Cnaan et al, Psychosocial Rehabilitation Journal, Vol. 11, No. 4: April 1988, p.61)

Cnaan et al state that psychosocial rehabilitation is based on a number of assumptions, including two essential ones

1. People are motivated by a need for mastery and competence in areas, which allow them to feel more independent and self-confident.
2. New behaviour can be learned and people are capable of adapting their behaviour to meet their basic needs.

The Psychosocial Rehabilitation Principles

Cnaan and his co-authors completed an extensive literature search in order to extract thirteen principles. They believed that only services which utilised all or most of these could claim to be involved in psychosocial rehabilitation. These principles have been constantly re-examined and two more have been added. In spite of the general acceptance of these principles, many organisations and practitioners have commandeered the term 'psychosocial rehabilitation' for almost any function perceived as different from the diagnosis and medical treatment of people with serious psychiatric illness.

In 1990, Cnaan and the same team attempted to validate the fifteen principles as the necessary requirement for defining a process as 'psychosocial rehabilitation'. The aim of the research was to examine whether the actual activities performed in psychosocial rehabilitation services in the U.S. correlated with the stated fifteen principles and vice versa. A generally high correlation was found for thirteen of the principles. This study went some distance in the development of a framework for a theoretical basis for psychosocial rehabilitation and certainly supported the contention that psychosocial rehabilitation is that set of processes based on at least thirteen of the principles as a necessary cluster. (Cnaan et al, Experts' Assessment of Psychosocial Rehabilitation Principles, Psychosocial Rehabilitation Journal, Vol. 13, No. 3, January 1990).

When these fifteen principles were examined in detail by the community- managed sector in Victoria in 1992, it was clear that there had been an increasing tendency in the literature to dilute the concept of psychosocial rehabilitation by paying less attention to the principals and processes and relying on more rigid 'technologies' - instrumental rather than fundamental approaches. It was decided to use the original set of principle as elucidated in Cnaan's paper in the 1988 Psychosocial Rehabilitation Journal rather than the 1990 version, as it reflected more precisely the original concept in a far more accessible language.

The fifteen U.S. Principles were

1. Under-utilisation of full human capacity.
2. Equipping people with skills (social, vocational, educational, interpersonal and others).
3. People have the right and responsibility for self-determination
4. Services should be provided in as normalised environment as possible.
5. Differential needs and care.
6. Commitment from staff members.
7. Care is provided in an intimate environment without professional, authoritative shield and barriers.
8. Early intervention.
9. Environmental approach.
10. Changing the environment.
11. No limits on participation.
12. Work-centred process.
13. There is an emphasis on a social rather than a medical model of care.
14. Emphasis is on the client's strengths rather than on pathologies.
15. Emphasis is on the here and now rather than on problems from the past.

Principles 14 and 15 were added by the 1990's as they were believed to be so strongly integral to the processes of psychosocial rehabilitation to warrant separate listing.

Victoria's Position

In 1992, the Victorian community-managed sector collectively decided that it was providing psychiatric disability support including psychosocial rehabilitation, rather than mental health services and this was reflected in the name change of its peak body. Organisations further delineated themselves as distinct from clinical services by adopting a set of Characteristics of Non- government Community-managed Community Mental Health Rehabilitation and Support Services in 1992. These were published in newparadigm, September 1992 and have remained the cornerstone of service delivery and support for the community- managed sector. They are:

1. Flexibility of structure and service models.
2. Non-obligatory attendance.
3. Support for mobility and choice of service options.
4. Active participant involvement in services.
5. Support for participant decision-making.
6. Concentration on quality of relationships and interactions between participants and staff.
7. Encouragement of peer support.
8. Responsiveness to participants' needs.
9. Provision of most 'normal' environment.
10. Effective psychosocial rehabilitation.
11. Autonomous community accountability.
12. Utilisation of a broad range of skills.
13. Active community education function.
14. Active advocacy function.
15. Cost-effectiveness: both operational and preventative.

At a VICSERV Forum in 1993, the community-managed psychiatric disability support sector reaffirmed the general acceptance of the psychosocial rehabilitation principles described by Cnaan and colleagues, with some important provisos.

In the first place it was necessary to ensure that psychosocial rehabilitation processes were receptive to the particular needs of its participants within the social, cultural, economic and political context of Victoria in the '90s. There was a recognition that Victoria is different from the U.S.

In the second place, it was felt that, although work, particularly in its broadest sense of 'activity' was an important element, it did not always reflect the hopes and aspirations of all participants. It was felt that the two necessary conditions for effective psychosocial rehabilitation as it was known by the community-managed sector were first the generation of hope and second the facilitation of social relationships. It was stressed that these, together with the principles of psychosocial rehabilitation, were most effectively achieved in settings consistent with the characteristics of community-managed disability support services quite separate and distinct from any clinical service.