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Chapter 28: Psychotherapies
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28.12 Psychiatric
Rehabilitation
Psychiatric rehabilitation denotes a wide range of interventions
designed to help people with disabilities caused by mental ill-
ness improve their functioning and quality of life by enabling
them to acquire the skills and supports needed to be success-
ful in usual adult roles and in the environments of their choice.
Normative adult roles include living independently, attending
school, working in competitive jobs, relating to family, having
friends, and having intimate relationships. Psychiatric reha-
bilitation emphasizes independence rather than reliance on
professionals, community integration rather than isolation in
segregated settings for persons with disabilities, and patient
preferences rather than professional goals.
Vocational Rehabilitation
Impairment of vocational role performance is a common compli-
cation related to schizophrenia. Studies across the United States
show that less than 15 percent of patients with severe mental
illnesses, such as schizophrenia, are employed. Nevertheless,
studies also show that competitive employment is a primary goal
for 50 to 75 percent of patients with schizophrenia. Because of
patient interests and historical factors, vocational rehabilitation
has always been a centerpiece of psychiatric rehabilitation.
Social Skills Rehabilitation
Social dysfunction is a defining characteristic of schizophre-
nia. People with the illness have difficulty fulfilling social roles,
such as worker, spouse, and friend, and have difficulty meeting
their needs when social interaction is required (e.g., negotiating
with merchants, requesting assistance to solve problems). Social
dysfunction is semi-independent of symptomatology and plays
an important role in the course and outcome of the illness. As
shown in Table 28.12-1, social competence is based on three
component skills: (1) social perception, or receiving skills;
(2) social cognition, or processing skills; and (3) behavioral
response, or expressive skills. Social perception is the ability to
read or decode social inputs accurately. This includes accurate
detection of affect cues, such as facial expressions and nuances
of voice, gesture, and body posture, as well as verbal content
and contextual information. Social cognition involves effective
analysis of the social stimulus, integration of current information
with historical information, and planning an effective response.
This domain is also referred to as
social problem solving.
Methods
The primary modality of social skills training is role play of
simulated conversations. The trainer first provides instructions
on how to perform the skill and then models the behavior to
demonstrate how it is performed. After identifying a relevant
social situation in which the skill might be used, the patient
Antonio is a 45-year-old man who has been a client of a mental
health agency for more than 10 years. He attended the rehabilitative
day treatment program until it was converted to a supported employ-
ment program. His case manager encouraged him to think about the
possibility of working part time. Antonio told his case manager that
he could not work because of his schizophrenia and because he was
helping to raise his two kids and needed to be home at 3 P.M., when
they returned from school every day. The case manager explained
to Antonio that getting a job does not necessarily mean working
40 hours a week and that lots of people in the agency’s supported
employment program were working in part-time jobs, even jobs that
only require a few hours a week.
Antonio agreed to meet one of the employment specialists to
discuss the possibility of work. Over the next couple of weeks, the
employment specialist met with Antonio several times, read his
clinical record, and talked with his case manager and psychiatrist.
The employment specialist learned that Antonio loved to drive his
car. He also learned that Antonio had attendance problems in past
jobs because he felt unappreciated. The employment specialist
found Antonio to be a sociable and likable person.
Antonio told the employment specialist that he was willing to
do any job. He did not have one specific job in mind. After discuss-
ing options with Antonio and with the team, the employment spe-
cialist suggested a job at Meals on Wheels as a driver for the lunch
delivery. Antonio was hired and loved it right from the start. Absen-
teeism was never a problem, because he liked driving around and
knew that people were counting on him for their meals. The hours
were perfect (10 A.M. to 2 P.M.), so he could be at home when his
kids returned from school. He became good friends with the other
workers. He told his case manager that it was wonderful to be bring-
ing home a paycheck again. And best of all, he said, was that his
kids saw him going to work just like their friends’ dads. (Courtesy
of Robert E. Drake, M.D., Ph.D., and Alan S. Bellack, Ph.D.)
Table 28.12-1
Components of Social Skill
Expressive behaviors
Speech content
Paralinguistic features
Voice volume
Speech rate
Pitch
Intonation
Nonverbal behaviors
Eye contact (gaze)
Posture
Facial expression
Proxemics
Kinesics
Receptive skills (social perception)
Attention to and interpretation of relevant cues
Emotion recognition
Processing skills
Analysis of the situation demands
Incorporation of relevant contextual information
Social problem solving
Interactive behaviors
Response timing
Use of social reinforcers
Turn taking
Situational factors
Social “intelligence” (knowledge of social mores and the
demands of the specific situation)
