Who cares for it? How to provide psychosocial interventions in the community

Abstract

Background:

Since the Mental Health Reform Law 1978/180, in Italy mental hospitals have been progressively closed and a community-centred psychiatric care oriented to rehabilitation began. After almost 35 years, the de-institutionalization process is now complete. However, psychosocial interventions in the community are provided only rarely, although a specific mental health professional, the psychiatric rehabilitation technician, has been established in Italy.

Material:

Training courses and the education of psychosocial rehabilitation technicians have been analysed and the university degree has been described. Moreover, the practical and theoretical skills needed at the end of the training course have been discussed.

Discussion:

Psychiatric rehabilitation technicians are trained to perform multidisciplinary rehabilitative and educational interventions for people with severe mental disorders and their carers. They represent an innovative professional workforce in mental health care, not yet established outside Italy, whose role and activities are essential in a community-based mental health system model.

Conclusion:

The skills needed for properly performing psychosocial interventions are not available in other mental health professionals and it is not possible that these interventions, which require in-depth training, are performed by professionals with a different background. It is advisable that psychiatric rehabilitation technicians become an integral and permanent component of an efficient community psychiatric staff.

Keywords

Psychiatric rehabilitation technicians in psychiatric rehabilitation mental health professionals psychosocial intervention community psychiatry

Introduction

On May 13, 1978, with the approval of the Mental Health Reform Law 180 (‘the so-called Basaglia law’), a new system of care for people with psychiatric disorders was defined in Italy. Mentally ill patients were no longer treated nor admitted in psychiatric hospitals, and care was provided exclusively in the community (de Girolamo, Barale, Politi, & Fusar-Poli, 2008). According to this law: (1) all mental hospitals had to be closed down; (2) psychiatric care had to be integrated into the national health system and had to be provided in residential facilities located in the community; and (3) compulsory admissions were possible only in particular and well-defined situations (i.e. patients refusing psychiatric care that is much needed and that cannot be provided outside the hospital) (Fiorillo et al., 2011).

Although the law explicitly considered the need to establish residential facilities with qualified professionals and technicians, and it defined a well-structured programme for psychosocial rehabilitation to be performed in the community, this unfortunately did not happen until recently (de Girolamo et al., 2007). The underpinnings of this reform law were the accumulating evidence at that time that patients may regain and develop lost skills allowing them to live effectively in their family and social context, despite psychological distress, suffering and disability induced by the illness (Magliano et al., 2002). According to the World Health Organization (WHO), rehabilitation of people with disabilities is a process aimed at enabling them to reach and maintain their optimal physical, sensory, intellectual, psychological and social functional levels (WHO, 2011). Therefore, psychiatric rehabilitation was defined as an autonomous process that should empower patients to regain and develop lost capabilities through appropriate paths (Corrigan, Mueser, Bond, Drake, & Solomon, 2008; Liberman, 2008), complementing drug therapy (Nierenberg, 2011; Oestergaard & Møldrup, 2011; Vauth, Dreher-Rudolph, & Stieglitz, 1999).

After almost 35 years, the de-institutionalization process has now occurred everywhere. However, psychosocial interventions in the community are provided only rarely, despite the role of psychiatric rehabilitation technicians, which represent an innovative workforce available only in Italy. Their particular task is to assist psychiatric patients in re-acquiring the skills that have been impaired by mental illness through appropriate and specific rehabilitation techniques (Davidoff, Lauga, & Walzer, 1969; Gill & Barrett, 2009). The education and training of these professionals have not been previously described, and their specific competences and tasks seem not very clear to many, despite evidence that they are more skilled than other mental health professionals in providing psychosocial interventions to persons with severe mental disorders and their relatives (Fiorillo et al., 2011). In fact, there is also some confusion about their name, and they are interchangeably called ‘rehabilitators’, ‘educators’ and ‘psychosocial professionals’. Some have referred to them as ‘those practising psychosocial rehabilitation’ (Piccinelli, Politi, & Barale, 2002).

In this paper we aim to shed light on the contribution of psychosocial rehabilitation technicians in the mental health care arena. In doing this, we will first describe their training and education, and only then will provide the readers with an overview of their roles and tasks.

University degree for technicians in psychiatric rehabilitation

The ministerial decrees issued on 29 March 2001 (Ministry of Health, 2001) and on 2 April 2001 (Ministry of University and Research, 2001) regulated and recognized the role of psychiatric rehabilitation technicians among health professionals. Consequently, a university degree programme in ‘psychosocial rehabilitation’ was established to train health professionals. To access the university degree course, students must hold the qualifications required by the law (i.e. to have a high-school diploma) and must pass an admission exam. In fact, the course has a limited number of available seats, which is decided annually by the Ministry of University and Research. Today, the course is available in as many as 20 Italian university sites and it is not present in any other country of the European Community, nor in other continents.

The structure of education

The course lasts three years, subdivided into six semesters. The first six months of the programme cover basic and general subjects; during the following five semesters, students go through more specialistic professional topics (see Table 1).

Table 1.

The programme of study of the degree course for technicians in psychiatric rehabilitation.

First year	First semester	Histology and Anatomy
		Physics, Statistics, Computer Science
		Biology, Genetics, Chemistry
		Foreign Language: English
		Introduction to Psychiatry
	Second semester	Physiology
		Neurology
		Psychological Sciences
		Nursing Sciences
Second year	First semester	Hygiene and Pharmacology
		Psychiatric Prevention, General Psychopathology, Rehabilitation and Therapeutic Communities
		Forensic Medicine
	Second semester	Behavioural, Cognitive, Family and Group Psychotherapy
		Child Neuropsychiatry and Growth Psychology
		Neuropsychiatric and Rehabilitation Techniques I
Third year	First semester	Psychopathology and Rehabilitation of the Elderly
		Neuropsychiatric and Rehabilitation Techniques II
		Business Management, Work and Organizational Psychology
	Second semester	Toxicology, Community Psychiatry
		Statistics for Experimental and Technological Research, Psychometrics
		Dynamic Psychology

Education is organized by frontal lessons and practical activities. In particular, practical sessions aim to enable students to acquire professional skills such as assessment, planning, implementation and monitoring of psychiatric rehabilitation techniques (Rele & Tarrant, 2010). Internship begins in the second semester of the first year. Students must attend a psychiatric clinic for 270 hours during the first year and for 310 hours in each of the following semesters. Clinical settings are changed every semester, so that students can deal with patients suffering from different mental disorders and disabilities, thus increasing their skills, abilities and knowledge on rehabilitation (Randall, Romero-Gonzalez, Gonzalez, Klee, & Kirwin, 2011). A tutor with clinical and rehabilitation experience is assigned to each student for continuous supervision throughout the six semesters.

At the end of the training course, students should have learned how to: (1) use assessment instruments, questionnaires and interviews for evaluating patients’ disability; (2) provide psychosocial interventions to patients with severe mental disorders; (3) work in multidisciplinary teams to plan and manage individualized psychosocial interventions; and (4) assess the impact of the provided interventions over time.

The final board examination, which is organized into two national sessions, one taking place in October/November and the other in March/April, consists of a practical and a theoretical part. In the former, trainees must show that they have acquired the necessary skills to manage a given rehabilitative situation, while the latter consists of an oral presentation on theoretical-experimental-applicative experiences made by the students during the course. At the end of the three-year training course, students can apply for a postgraduate specialistic degree in professional rehabilitation, available in 17 Italian university sites and whose course lasts two years.

Training objectives

On the basis of the principles of psychiatric rehabilitation (Corrigan et al., 2008; Hume & Pullen, 1986; Liberman, 2008), the specific aims of training are to: (1) assess patients’ mental disabilities, available abilities and personal, family and social resources, as well as their motivation and needs; (2) identify, in collaboration with the patient, therapeutic and rehabilitation objectives and formulate a specific intervention programme tailored to patients’ needs and aimed at their personal recovery; (3) improve patients’ care and self-care, enhance interpersonal relationships and explore employment opportunities; (4) prevent mental disorders in the community, through educational campaigns for target populations, and conduct anti-stigma campaigns, in order to facilitate the acceptance of the mentally ill in the community; (5) prevent patients’ risk behaviours or help them to be able to manage difficult situations; (6) involve patients’ relatives, friends and caregivers in their integration process in the community; and (7) assess patients’ psychosocial outcomes.

The practical training provides specific skills of essential importance for a future career, such as communication skills, and assertiveness- and empathy-based techniques. Theoretical knowledge and practical skills, in their intertwining educational roles (Rabboni, 2005), on different rehabilitation techniques aim at increasing future professionals’ flexibility and eclectics in everyday clinical work.

Moreover, the two-year post-specialistic degree allows psychiatric rehabilitation technicians to acquire the scientific knowledge, ethical values and skills needed to provide health care and education, as well as to manage budget-related problems of children, adults and the elderly in their community.

Role and tasks of technicians in psychiatric rehabilitation

Psychiatric rehabilitation technicians are an innovative professional workforce in mental health care, not yet established outside Italy, but whose role and activities are essential in a community-based mental health system model. These professionals are specialized in the psychosocial recovery of people with psychiatric disabilities, and their interventions include basic and specialistic rehabilitative programmes, provided both in an individual and a group format, such as cognitive behavioural therapy, social skills training, psycho-educational family and individual interventions, cognitive remediation, problem solving, relaxation, counselling, occupational therapy and other techniques in patients suffering from various mental disorders, including psychosis, mood disorders, personality disorders, eating disorders, anxiety disorders and disturbances of the elderly (Eckman, Liberman, Phipps, & Blair, 1990; Eisenberg & Cole, 1986; Falloon, 2004; Mueser, Valenti-Hein, & Yarnold, 1987).

In order to apply these techniques, the following skills – which will be essential for the profession – must be learned by students:

Basic knowledge on psychiatric rehabilitation (history and evolution of psychiatric rehabilitation; psychiatric psychopathology; analysis of the notion of normality, health, sickness, disability and handicap; mental health service organization, such as institutional goals, the multi-professional team, the organization chart; stigma).

Being members of multidisciplinary teams (actively participating in all decisions regarding the patient, providing their knowledge and expertise).

Communication skills (establishing and maintaining a trustworthy relationship with the patient, but also with his/her relatives and social network; recognizing the differences between professional relationships and friendships; undertaking actions aimed at promotion and prevention in mental health).

Learning skills (considering problems as a possibility for improving knowledge and selecting and reading scientific papers).

Psychiatric rehabilitation technicians should ideally work for multi-disciplinary teams in public health services; they may also work for private enterprises for mental health care, due to the shortage of job positions available in public settings. However, whatever the setting, they are responsible for running and coordinating individualized and specific rehabilitative plans for the patient, on the basis of the assessment of his/her needs.

Difficulties and future perspectives

Despite such good organization, and although the psychiatric reform law has now been established for more than 30 years, the implementation of community-oriented mental health services has not been really successful everywhere (de Girolamo et al., 2007). In fact, mental health centres still provide mainly pharmacological treatments, while rehabilitative interventions are provided in as many as 30% of patients with schizophrenia, and psycho-educational family interventions – i.e. the best evidence-based psychosocial treatment – are provided to only 8% of patients. The lack of psychiatric rehabilitation technicians employed in public community settings may probably explain why most patients with severe mental disorders do not receive appropriate psychosocial interventions. One may argue that the employment of these professionals would pose further economic burden on mental health care in a period of general financial crisis; however, the provision of psychosocial interventions is associated with a significant reduction of costs of mental health care, through a reduction of inpatient bed use and of involuntary hospitalizations (McDaid, 2007). Moreover, the fact that these interventions are very helpful in reducing family burden, which is another source of (indirect) costs due to loss of productivity of family members (de Girolamo et al., 2007; Magliano et al., 2002), gives another reason for the need to provide them.

With the increase of residential facilities (Fiorillo et al., 2011; Magliano et al., 2002; Neri et al., 2011; Priebe et al., 2005), one would have expected an increase of specialized personnel employed in these settings. Unfortunately, this has not been the case not only in Italy (Neri et al., 2011), but also in the UK (Lelliott, Audini, Knapp, & Chisholm, 1996; Senn, Kendal, & Trieman, 1997) and the USA (Randolph, Ridgway, & Carling, 1991), where an increase of non-specialized employees has been observed. This has obvious consequences on both patients, who receive care from staff not adequately trained, and on professionals, who deliver treatments without having the appropriate skills and knowledge. In a survey recently carried out among newly graduated rehabilitation technicians (Pingani, Catellani, Vinci, Ferrari, & Rigatelli, 2011), more than 80% of subjects found employment within the first six months after graduation, 75% of them being employed in the private sector. However, respondents pointed out that the job was only partially consistent with their studies.

Conclusions

It is advisable that psychiatric rehabilitation technicians become an integral and permanent component of an efficient community psychiatric staff. The university degree programme here described has been available in Italy for only 11 years now; this is a relatively short period and this could be the reason why this professional role is still so undetermined in community mental health services (Neri et al., 2011). However, the awareness for the need to employ staff specifically trained in the treatment of psychiatric disability is increasing, as confirmed by a high postgraduate employment rate within one year after graduation and by the fact that about 80% of graduates subsequently undergo further specialization university courses (e.g. master’s).

The skills needed for properly running psychosocial interventions are not available in other mental health professionals, nor can these interventions, which require in-depth training, be performed by professionals with a different background. Psychiatrists, psychologists and community psychiatric nurses have different skills and are employed with different purposes (Magliano et al., 2006). Psychiatric rehabilitation technicians are necessary, unless we want to revert to an era when rehabilitation was entertainment and not the delivery of evidence-based psychosocial interventions (Saxena et al., 2007). Something we, and no doubt the readers, do not want.

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