Definition of Medical Rehabilitation A full definition of medical rehabilitation should contain three parts. The first is a statement of aim: ideally, to settle or resettle an individual in his normal domestic setting, and in work appropriate to his talents. Most patients and doctors can measure their success against these two practical indices, although what is regarded as socially desirable varies widely and some individuals prefer a highly idiosyncratic way of life.

Rehabilitation of Psychiatric Patients

Although most chronically impaired psychiatric patients now reside in community-based residential homes, a substantial number show little progress in their social rehabilitation. To establish the rehabilitative needs of this population, the current study sought to examine the social behaviour of residents of a large residential care facility. After an analysis of the social behaviour of all residents, two groups were selected for detailed study on the basis of their contrasting patterns of social interaction. These two groups were found to differ significantly with respect to their interpersonal activity, social contact, conversation skill, employment, and participation in community rehabilitation programmes. Psychiatric status was substantially different in each group. The implications of these findings for rehabilitation strategies in the management of severe mental illness are discussed.

https://www.cambridge.org/core/services/aop-cambridge-core/content/view/S0033291700050960

Residential care and social behaviour: a study of rehabilitation needs.

The title of this paper requires explanation. In the early part of the nineteenth century, such care as people with schizophrenia received was given “in the community,” not in hospital. Attitudes toward institutional and community psychiatry have changed over the years. The first psychiatric hospitals were set up, both in Britain and in the United States, in reaction against the appalling conditions of “community care” then prevailing [12,22]. They were small, with a high turnover, and in the best of them the staff fostered a family atmosphere, with emphasis on moral treatment, the ideals of which were not altogether dissimilar to those fashionable during the past 20 years, and took pride in the fact that they used no methods of physical restraint. Since then, the balance of advantage to the patient, of receiving care inside hospital compared with receiving care outside it, has swung both ways, but it has never been an absolutely clear-cut decision as to which was preferable; there has always been something to be said on both sides. The psychiatric hospitals, in both our countries, went through a prolonged period in which patients experienced pauperism, neglect, institutionalism, restraint, and occasionally cruelty.

The Management of Schizophrenia in the Community

1. Rehabilitation is defined as the process of restoring a handicapped person to a situation in which he can make the best use of his residual capacities within as normal as possible a social context. - 2. The legislation which allowed many of the recent advances to take place is described. - 3. Psychiatric illness can be thought of as producing two sorts of disability.Primary handicaps are the chronic symptoms of illness together with the accumulated loss of skills through disease.Secondary handicaps consist of unhealthy personal attitudes to illness together with unfavourable attitudes adopted towards the patient by relatives, employers and hospital staff. Rehabilitation schemes do not so much attempt to modify the chronic symptoms of psychosis as aim at decreasing or preventing secondary handicaps and at increasing the social acceptability of patients. - 4. In recent years progressively more hospitals have started industrial units, and various specialised rehabilitation units have been opened.- 5. Many studies have shown that money and rather crude psychological incentives fail to increase the output of schizophrenic patients under experimental conditions. Social incentives, however, when given in natural and less arbitrary conditions, do seem to work quite well. - 6. The beneficial effects of courses at Industrial Rehabilitation Units are described in detail. Problems of psychiatric entrants are shared with, and similar to, those of a large proportion of nonpsychiatric entrants. - 7. Discharged long-stay patients impose a considerable burden on the community, and when readmission does occur it tends to follow recrudescence of symptoms. The patient's ability to stay out of hospital is significantly related to the type of living group to which he is discharged. - 8. The problems of short-stay schizophrenic patients are not dissimilar in general (although they differ in detail) to those of long-stay patients. The tendency to develop secondary handicaps is still present, and rehabilitation techniques which have been developed for use in hospitals need to be adapted for use in the community as well.

Rehabilitation of the chronically mentally ill in England

The investigation reported here attempted to carry out an objective comparison of certain psychological, clinical and social effects following upon Workshop therapy, Occupational Therapy and the absence of any specific activity for male chronic schizophrenics. The data obtained showed that while all three conditions led to improvements on the measures employed, the group receiving Workshop therapy improved to the greatest extent. The most important changes were in terms of social competence, clinical state, reaction time, and accuracy of estimation. It has been shown that most of these measures were linked in terms of changes on them by significant correlations, and the assumption has been made that the measures reflect important capacities involved in industrial efficiency and adaptability.

Separate and controlled manipulation of financial reward and Workshop structure indicated: 

1. That the major behavioural changes occurred when patients were paid on a flat rate basis and were working independently of each other;

2. That consistent behavioural changes for the Workshop group continued to occur while patients were paid on a piecework basis working both independently of each other and as members of a team, but that these changes were not significant;

3. That holding absenteeism constant, the prospect of earning more money did not lead to significantly greater output;

4. That team work compared with working individually appeared to lead to additional changes on the behavioural measures used, and

5. That holding absenteeism constant, output and earnings were greater for patients working as teams than for patients working individually.

Since opportunity for increased earnings did not lead to significantly greater output, and since opportunity for increased earnings is a normal positive incentive in our industrial culture, the conclusion is implicit, though not substantiated beyond doubt, that financial reward as well as changes in type and amount of reward did not play a crucial part in the behavioural changes observed. In view of the remaining doubts, however, concerning the absolute role of financial reward as such, further investigations in this area are planned.

What appears to be important is the total effect of what might be called the “workshop climate”. This “climate” may be seen as an amalgam of industrial work, male supervision, time keeping, payment, and working in the company of other men on a socially approved task. They are features which are an integral part of a normal working situation and which convey a definite though non-specific socio-psychological climate. It is this “climate”, which was experimentally enhanced by organizing teams of patients, which in turn led to the rise in output and earnings and a decrease in absenteeism. It is held to be the same total situation which led to the superior and consistent changes of the Workshop group in the behavioural areas tapped by the test battery. It was tentatively suggested that the amount of change recorded might be due to a general re-activation of patients expressed in changes in alertness, awareness, responsiveness and objectivity.

K. Rawnsley

Papers

Incentives with paranoid and non-paranoid schizophrenics in a workshop.