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The Importance of PSR for Individuals with Mental Illness

Discuss about the Caregiver Burdens and Psychiatric Symptoms.

Psychosocial rehabilitation (PSR) is the approach to promote personal recovery and satisfactory quality of life for people living with mental illness or mental disorder. PSR services are collaborative and person-centred care services that focus on supporting mentally ill patient to develop skills and access resource to live a high quality of life (Kopelowicz, Liberman, & Zarate, 2006). PSR is important for mentally ill patient because of their dependence on daily life activities and their inability to adjust to the conditions, the disabilities and their environment. Although medical or pharmacological interventions are also provided to mentally ill patients, however satisfactory level of functional recovery and attainment of social skills is not possible through medication alone (Gühne et al., 2015). Hence, to promote holistic recovery of patient, appropriate form of PSR along with other treatments are necessary for mentally ill patient. In the past, family influence was regarded as a cause of mental illness. Today, involvement of family in the process is recognized as an important element of the rehabilitation (Pratt et al., 2006). The main purpose of this essay is to critically evaluate the role of family in the rehabilitation process and assess the effectiveness of family involvement on empowering mentally ill patients.

Mental illness is a highly prevalent health issue due to exposure to traumatic life events and different stressors in life. Diagnosis of serious mental illness like major depressive disorder  and schizophrenia leads to major form of psychiatric disability in a person (Fairweather et al., 2017). In case of adolescents, it may interfere with normal development process. In case of adults, it interrupts with daily life functioning and work priorities of a person. Negative social and work experience due to diagnosis of mental disorder also has a profound impact on interpersonal and social functioning of adults. For example, experience of stigma act as a barrier to help-seeking (Clement et al., 2015). In such condition, they are in need of people who understand their unique needs in life and support them to overcome challenges in life due to disabilities (Afilalo et all., 2015) . PSR has been developed to provide care to mentally ill people who struggle with the above mentioned challenges. One of the key principle of PSR is patient oriented focus, where value is placed on identifying individual needs of people with mental illness and assessing their ability to function and complete activities of daily living. PSR aims to increase the provision of support and encouragement by providing in accordance with unique environment of patient (Pratt et al., 2006). This may include incorporation of cultural preference, social values and client’s choice in the rehab process. It can also be regarded as strength based approach to care as the process aims to utilize strength of client as a framework for individualized goal setting. Effective collaboration is also a necessary aspect of PSR as communication with client helps an individual to rediscover their skills and access appropriate community resource to live a fulfilling and high quality life (Foster et al., 2016).

The Role of Family in the Rehabilitation Process


Current research suggests that involvement of family in PSR process is crucial to increase commitment of patient to recovery. Family involvement is regarded as an effective strategy because of poor commitment and engagement of mentally ill patient in treatment process. Dixon, Holoshitz and Nossel (2016) argues that individual living with serious mental illness are often difficult to engage in  on-going treatment and poor engagement leads to exacerbation of symptoms and increase in length of hospital stay. Hence, due to issues of disengagement, patients fail to fully realize the benefits of treatment. Due to these issues in the care of patients with mental illness, recovery oriented care like PSR focused on delivery of family driven care so that patients receive positive reinforcement from family members (Kopelowicz, Liberman, & Zarate, 2006). Collaboration between family members, patients and rehabilitation staffs is an approach to respond to individual needs in the context of history, strengths, quality of life outcomes and recovery plans for individual patient. Family members provide the right information to assist rehab staffs in planning ways to develop skills and motivate patients (Foster et al., 2016).

In the past, families were regarded as etiological agents causing mental illness. For example, family psychosocial factors such as criticism, hostility and violence contributed to risk of mental illness in children. Hence, families were excluded from treatment plan. However, now a paradigm shift has taken place. Families are now included in PSR to build resilience of people living with mental illness and increase their coping skills (Janardhana & Naidu, 2012). Psychosocial intervention has the potential to reduce relapse rate and prevent rehospitalisation. Psychosocial interventions are now targeting families to reduce care giving burden and overcome stress due to management of health of their family members. The rational for working with family members is to provide education regarding mental illness, problem solving and overcoming crisis situation. PSR offers therapeutic strategies to improve the quality of life for the family as well as decrease the possibility of relapse for patient (Srivastava & Panday, 2016). Notwithstanding the benefits of family engagement, some of the barriers associated with its uptake is that mental health professionals lack the skills and knowledge to engage effectively with family members. In addition, lack of clarify regarding family focused practice may also act as a barrier in the process (Foster et al., 2016).


Another rational to support inclusion of family in the PSR process is that family members act as a great source of support for patients with mental illness and they increase sense of belonging for patients. Proper collaboration and coordination with families can support rehab staffs to understand the reason for non-adherence to medication or presence of agitation in a particular patient. They give useful client-centred idea regarding the reasons for mental illness and ways to tackle an aggressive client. They can encourage engagement with treatment plans and supporting rehabilitation staffs to identify and respond to early signs of relapse (Ingoldsby, 2010). Due to such benefits, families are involved in PSR to promote better quality of living and increasing efficacy of pharmacological therapies too. PSR is a collaborative and person-directed care services and rehab staffs focus on psycho-education of families and consumers to ensure that they possess reasonable expectation regarding mental illness and its rehabilitation process. The efficacy of psycho-educational family intervention for patients with mental illness in understood by the study by Ran et al. (2015). The study gave an overview about the long-term impact of psych-educational family intervention for patients with schizophrenia. By means of a randomized controlled study design, the study proved that people in the psycho-educational family intervention group had high rate of help seeking behavior and improvement in social functioning such as high rate of full and part time work ability (Ran et al. 2015). Hence, the evidence by (Ran et al. 2015) shows that psycho-education family intervention in the mental health rehabilitation process produce long-term effect and increase patient’s adherence to treatment and work ability too.

Benefits and Challenges of Family Involvement in PSR

Psycho-education in a PSR program also support family members to manage stress during care giving process and learn specific skills to empower their loves ones and promote health.          This is necessary to develop family members as the caring agent for patient. They must have the skills to cope with both positive and negative symptoms of mental illness. It is often seen that negative symptoms have most devastating effect on patients as well as families. Due to lack of mental health service resources in low income countries and history of deinstitutionalization in high income countries, the ultimate burden of care falls on the family members. Strained relationship with families and poor quality of life in family care giver arise because of inability to provide ideal support. Troublesome action of people with mental illness such as hostile behaviour, mood swings, poor personal hygiene, poor motivation and socially offensive behaviour also contributes to burden. In this situation, negative coping strategies like negative thinking and substance abuse becomes common in people compared to positive coping strategies like utilization of appropriate social supports such as family, friend and health care professionals (Marimbe et al., 2016).  This affects productivity of family caregiver and their own mental well-being too.  Hence, PSR program emphasizes on involvement of family members in care process so that they learn to cope with negative symptoms too.


In evidence based practice, family interventions focusing on psycho-education and coping strategies have proved the effectiveness of these intervention in promoting recovery of patients. Today, family psycho-education and support intervention involve family members extensively in the rehabilitation process and promote independence of patients. Mental health care professionals prioritize providing education to family members regarding symptoms and medication, techniques for managing difficult behaviour and involvement in support group. ­­ Sharif, Shaygan and Mani (2012) explains that among variety of family interventions to reduce care giving burden, psycho-education is considered more useful in reducing the burden compared to family therapy and behavioural family intervention.  Psycho-education mostly focus on addressing patients and family needs by increasing knowledge about disease, adjustment to mental illness and promoting problem solving skills in patient. Psycho-education intervention influences burden, quality of life, health outcome as well as social skills of patients and families. Ducharme et al (2015) proved the efficacy of psycho-educational intervention on improving clinical status of patient and reducing care giving burden.  Although the crucial role of family members in the rehabilitation process has been proved, socio-cultural barriers may act as a challenge in engaging families in rehab process. This is because many people might be uncomfortable in discussing their experience with mental illness. Hence, to eliminate these barriers in the rehabilitation process, developing of communication and negotiation skills of health care professionals will be crucial.

Effective Family Engagement Strategies in PSR

To successfully involve family members in PSR, the use of six practices is essential with family and patients. This includes goal setting, liaison with families and services, emotion, social and resource support, assessment of family functioning, psycho-education and coordinated system of care. After analysis of patient’s need in consultation with family members and evaluation of specific alternative for patient, evaluation of alternative or structured approach to problem solving will be important for patient. Swift et al. (2017) has reported about the insufficiency of pharmacotherapy alone in treating person with chronic mental illness. Hence, there has been a paradigm shift towards integration of rehabilitative model and family perspective on collaborative approach to care. Apart from family based interventions, other interventions available to empower people living with mental illness include vocational rehabilitation, skills trainings and cognitive behavioural therapy. Skills training are important because of deficits in social and adaptive skills of patients (Kramers-Olen, 2014). Skills training intervention in PSR employs behavioural approach to facilitate learning of new skills. This form of training can also be done with family members to resolve family communication issues and stress in family relationship due to burden of illness. The positive outcome of the intervention is that when family members realize the benefits of the new skills acquired, they can support and empower patients to reinforce those skills in the home setting too. There is also evidence regarding the effectiveness of integrating skills training with other intervention to improve psychotic symptom, quality of life, family stress and disability of patients (Kopelowicz, Liberman, & Zarate, 2006). From the review of PSR intervention and the involvement of family members in these interventions, it is clear that family engagement can play a beneficial role in motivating patients and empowering them to adapt new skills for recovery.


The essay summarized the need for PSR as a form of patient centred care approach for mentally ill patients. PSR is a person-oriented care approach where well-being of patient is promoted by placing value on individual needs and respecting unique environment of patient. The essay presents a critical insight into the role of family members in the care giving process. In the past, families were excluded from care process as they were regarded as etiological agent of change. However, current treatment process has undergone a paradigm shift where family involvement is considered important to get unique information about patient, reinforce positive behaviour and motivate patients to adapt new behaviour and lead a high quality of living. The effectiveness of family involvement in PSR has been supported in the essay with support from various evidences. Certain challenge in family involvement has also been identified. Working on those challenges is crucial to achieve therapeutic goals for people with mental illness.

Barriers Associated with Family Engagement in PSR

Reference:

Afilalo, M., Soucy, N., Xue, X., Colacone, A., Jourdenais, E., & Boivin, J.-F. (2015). Characteristics and Needs of Psychiatric Patients With Prolonged Hospital Stay. Canadian Journal of Psychiatry. Revue Canadienne de Psychiatrie, 60(4), 181–188, doi:  10.1177/070674371506000405

Clement, S., Schauman, O., Graham, T., Maggioni, F., Evans-Lacko, S., Bezborodovs, N., ... & Thornicroft, G. (2015). What is the impact of mental health-related stigma on help-seeking? A systematic review of quantitative and qualitative studies. Psychological medicine, 45(1), 11-27, doi:10.1017/S0033291714000129

Dixon, L. B., Holoshitz, Y., & Nossel, I. (2016). Treatment engagement of individuals experiencing mental illness: review and update. World Psychiatry, 15(1), 13–20. https://doi.org/10.1002/wps.20306

Ducharme, F., Lachance, L., Lévesque, L., Zarit, S.H. and Kergoat, M.J., 2015. Maintaining the potential of a psycho-educational program: efficacy of a booster session after an intervention offered family caregivers at disclosure of a relative's dementia diagnosis. Aging & mental health, 19(3), pp.207-216,  doi: 10.1080/13607863.2014.922527.

Fairweather, G. W., Sanders, D. H., Cressler, D. L., & Maynard, H. (2017). Community life for the mentally ill: An alternative to institutional care. Routledge, Retrieved from: https://www.taylorfrancis.com/books/9781351527385

Foster, K., Maybery, D., Reupert, A., Gladstone, B., Grant, A., Ruud, T., ... & Kowalenko, N. (2016). Family-focused practice in mental health care: An integrative review. Child & Youth Services, 37(2), 129-155, DOI: 10.1080/0145935X.2016.1104048

Gühne, U., Weinmann, S., Arnold, K., Becker, T., & Riedel-Heller, S. G. (2015). S3 guideline on psychosocial therapies in severe mental illness: evidence and recommendations. European archives of psychiatry and clinical neuroscience, 265(3), 173-188, DOI 10.1007/s00406-014-0558-9

Ingoldsby, E. M. (2010). Review of Interventions to Improve Family Engagement and Retention in Parent and Child Mental Health Programs. Journal of Child and Family Studies, 19(5), 629–645. https://doi.org/10.1007/s10826-009-9350-2

Janardhana, N., & Naidu, D. M. (2012). Inclusion of people with mental illness in community based rehabilitation: Need of the day. International Journal of Psychosocial Rehabilitation. Vol 16 (1) 117, 124, 15-45, Retrieved from: https://www.psychosocial.com/IJPR_16/Inclusion_of_People_Janardhana.html

Kopelowicz, A., Liberman, R. P., & Zarate, R. (2006). Recent Advances in Social Skills Training for Schizophrenia. Schizophrenia Bulletin, 32(Suppl 1), S12–S23. https://doi.org/10.1093/schbul/sbl023

Kramers-Olen, A. L. (2014). Psychosocial rehabilitation and chronic mental illness: International trends and South African issues. South African Journal of Psychology, 44(4), 498-513, DOI: 10.1177/0081246314553339 sap.sagepub.com

Marimbe, B. D., Cowan, F., Kajawu, L., Muchirahondo, F., & Lund, C. (2016). Perceived burden of care and reported coping strategies and needs for family caregivers of people with mental disorders in Zimbabwe. African Journal of Disability, 5(1), 209. https://doi.org/10.4102/ajod.v5i1.209

Pratt, C. W., Gill, K. J., Barrett, N. M., & Roberts, M. M. (2006). Psychiatric rehabilitation. [Electronic version]. In Psychiatric Rehabilitation, The Role of the Family in Psychiatric Rehabilitation, 373-400. Elsevier Academic Press. Retrieved from https://ebookcentral.proquest.com 

Ran, M. S., Chan, C. W., Ng, S. M., Guo, L. T., & Xiang, M. Z. (2015). The effectiveness of psychoeducational family intervention for patients with schizophrenia in a 14-year follow-up study in a Chinese rural area. Psychological medicine, 45(10), 2197-2204, doi:10.1017/S0033291715000197

Sharif, F., Shaygan, M., & Mani, A. (2012). Effect of a psycho-educational intervention for family members on caregiver burdens and psychiatric symptoms in patients with schizophrenia in Shiraz, Iran. BMC Psychiatry, 12, 48. https://doi.org/10.1186/1471-244X-12-48

Srivastava, P., & Panday, R. (2016). Psychoeducation an Effective Tool as Treatment Modality in Mental Health, DOI: https://www.researchgate.net/publication/318461551

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Swift, J. K., Greenberg, R. P., Tompkins, K. A., & Parkin, S. R. (2017). Treatment refusal and premature termination in psychotherapy, pharmacotherapy, and their combination: A meta-analysis of head-to-head comparisons. Psychotherapy, 54(1), 47, Doi: https://dx.doi.org/10.1037/pst0000104

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