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Table of Contents
Year : 2023  |  Volume : 5  |  Issue : 1  |  Page : 47-50

Global Aspects of Psychosocial Rehabilitation

Chairperson Anti Torture Support Foundation Copenhagen, Denmark

Date of Submission06-Mar-2023
Date of Decision06-Mar-2023
Date of Acceptance06-Mar-2023
Date of Web Publication26-Apr-2023

Correspondence Address:
Prof. Marianne Kastrup
Marianne Kastrup, Amalievej 23, DK 1875 Frederiksberg
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/wsp.wsp_3_23

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Rehabilitation is required when limitations in health prevent full functioning. On a global level, WHO estimates that more than 2.4 billion could benefit from a rehabilitative intervention of some kind. The health limitations may have several causes frequently with a mental health dimension and the benefits of psychosocial rehabilitation are increasingly recognized globally. An example is given of a psychosocial model focusing on traumatized individuals and the development of a rehabilitative field manual to be used in Low and middle income countries (LOMIC) or settings of limited resources.

Keywords: Globalization, mental health services, rehabilitation, treatment packages

How to cite this article:
Kastrup M. Global Aspects of Psychosocial Rehabilitation. World Soc Psychiatry 2023;5:47-50

How to cite this URL:
Kastrup M. Global Aspects of Psychosocial Rehabilitation. World Soc Psychiatry [serial online] 2023 [cited 2023 May 29];5:47-50. Available from: https://www.worldsocpsychiatry.org/text.asp?2023/5/1/47/374622

  Introduction Top

There is currently a significant variability in how rehabilitation services are described and understood.[1] According to the WHO Director-General T. A: Ghebreyesus,[1] rehabilitation comprises the interventions needed when a person is experiencing limitations in everyday physical, mental, and social functioning. The reasons behind this include any health condition, injury, or trauma. Community-based rehabilitation goes back to the WHO Declaration of Alma-Ata 1978 with the effort to ensure participation and promote the quality of life of persons with disabilities.[2] The aim of rehabilitation is to help the person to become as independent as possible in performing everyday activities and to enable participation in education, work, recreation, and family life. The WHO estimates[1] that 2.4 billion people live with conditions that could benefit one way or another from rehabilitation which reflects the huge need for rehabilitative interventions worldwide. However, despite an obvious need a large proportion in want of rehabilitation is not receiving adequate help, in particular in LOMIC countries.[3]

  Definition and Delineation Top

Rehabilitation is helping the individual to overcome difficulties, for example, using their faculties, and by providing, adapting, and training in the use of assistive products. Among the significant reasons behind the need for rehabilitation you find the increased life expectancy, the increased number of elderlies, the many chronic noncommunicable diseases, and different health emergencies.

As a consequence, the WHO has launched a 2030 call for action to encourage stakeholders to strengthen health systems and has supported a number of countries in providing rehabilitation services, including services in the area of mental health.[4] Together rehabilitation agencies, public health authorities, WHO and other stakeholders shall work for implementing rehabilitation services globally as part of their core business with the words of Ghebreyesus “rehabilitation is an essential component of Health for All.”[1]

Regardless of setting and form, there are certain communalities in the rehabilitative approach and the principles behind. All human beings have potentials that may be developed under the right circumstances; the needs may differ, but the focus should be on strengths rather than deficiencies. Moreover, we all have a right for selfdetermination, irrespective of background, and this self-determination should be encouraged in surroundings as normalized as possible. Rehabilitation may take several forms, one of the forms of rehabilitation is the psychosocial one.

  Psychosocial Rehabilitation Top

Psychosocial rehabilitation may be defined in many ways. However, the general consensus is that it is a rehabilitative approach designed to help improving the lives of people with mental illness. This approach is based on a set of principles designed to teach the persons emotional, cognitive, and social skills to help them live and work in their communities as independently as possible.[3]

The rehabilitative process is facilitated by focusing on empowerment, where the individuals should set their own goals and be supported – if necessary in pursuing these. Interventions should have focus on the quality of life and helping the individuals to envisage the future with hope. A major role of mental health professionals is to facilitate this process and help in building sustainable relationships in the community. In many ways, psychosocial rehabilitation may be seen as linked to the ideology of the deinstitutionalization movement aiming to allow mentally ill persons to live as independently as possible. In other words, it is an attempt to provide the best possible community role that enables patients to achieve the maximum range of activity and interests of which they are capable.

  Who Benefits? Top

Do all persons with psychiatric illness need psychosocial rehabilitation? The answer is no; all may benefit from rehabilitation, but not all need it. For some, for example, psychopharmacological medication or psychotherapy may be quite sufficient. For others, a psychosocial rehabilitative intervention may be required in particular if the person is requiring assistance in several domains of life or if the person may be devoid of supportive network.[3]

  Global Aspects Top

In 2017, WHO launched a global action: rehabilitation 2030.[4] The objective was to highlight the unmet need for rehabilitation around the globe but also to emphasize the need to improve management, collect data and build high-quality services.[4] In 2019, this action plan was added a discussion of strategies how to make rehabilitation a political priority. For WHO, a high priority was given to focus on providing accessible and affordable rehabilitative services in low- and middle-income countries.

From a public health perspective, it is a global goal to optimize functioning at all ages and for persons of all backgrounds, and here rehabilitation is unique in its approach. In its call for action, the WHO has listed 10 areas of action and among them emphasizing the need for responsible leadership and political support on all levels, global, national, and local.[4] Rehabilitation should be an integrated part of health coverage, be fully integrated into the health sector, and properly financed. Progressive and comprehensive rehabilitation models should be developed to provide equitable access to adequate services together with a multidisciplinary workforce. Providing adequate rehabilitation is a dynamic process requiring a continuous monitoring and data-collection of essential data with a focus on international applicable health information systems. Furthermore, the continuous development of rehabilitative interventions necessitates ongoing research activity to assemble robust evidence of the most efficient models of rehabilitation in a given setting.

  Package Model Top

Public management with the standardized model of treatment or rehabilitation and the strict number of resources available has become a very common approach in many modern health-care facilities.[5] The idea is to provide a fixed model with a standardized offer of rehabilitation comprising a certain number of consultations, kinds of interventions, number and kinds of staff involved, etc.

There are both advantages and drawbacks using this model. Among the advantages are the limited variability in the care offered meaning that all will be provided the same service irrespective of ethnic, economic, or social background; and that all receive standard care. However, one size does not fit all, and the model does not allow for taking individualized considerations according to individual needs. Furthermore, patients may be discharged from rehabilitation without having fully recovered if all resources allocated to the intervention have been used. Hence, to maximize the outcome of rehabilitation, a mixture of the two approaches may be the optimal solution.

  An Example of Psychosocial Rehabilitation Top

As an example of psychosocial rehabilitation from a global perspective, the rehabilitative work for torture survivors in Denmark represents one model. The centerinitially named Rehabilitation and Research Center for Torture Victims changed in 2012 name to the current name Dignity Danish Institute against Torture - was started in 1982 as a selfgoverning rehabilitative service with responsibility for traumatized populations coming from all parts of the world.[6] Already in 1985, the International Council for Torture Victims was established as an international umbrella organization for rehabilitation centers globally. The center has expanded its activities over the years adding new dimensions of its work and collaborating with several similar organizations around the world. The derivative fields include the development of new knowledge about rehabilitation, teaching and developing teaching material to different professional groups, carrying out research on the outcome of rehabilitation, and supporting authorities in the South in the development of a strong civil society.[6]

A core function is still the psychosocial rehabilitation clinic that has status as a highly specialized national center in Denmark approved by the National Board of Health specializing in the rehabilitation of severely traumatized individuals and their families. The approach is interdisciplinary, biopsychosocial with the participation of medical, psychological, physiotherapeutic, and social counseling expertise. Based on a thorough assessment, the rehabilitative process may be individual, carried out in groups or with a holistic family-directed approach.

  Field Manual of Rehabilitation Top

One of the many outcomes of the rehabilitation work was the Field Manual of Rehabilitation from 2007.[7] The aim was to meet the need for evidence-based or consensus-based advice to rehabilitate victims of organized violence in regions of the world with limited resources and a shortage of specialized medical care. The intention was to provide practical recommendations for health workers at different skill levels in difficult situations with limited, if any specialized care available. The manual may be downloaded from the dignity website.[8]

The manual has an interdisciplinary and integrated approach and assembles all aspects not only using an academic approach but also comprising complementary, alternative medicine with respect for different religious, cultural, and spiritual values.

The idea lying behind is that general knowledge and cultural traditions in the community are important for a satisfactory outcome of the rehabilitation efforts and that a Western model of health should not be imposed without acknowledging local customs and practices.

Each entry defines a problem that is globally developed and recognized. The different entries are based on the WHO International Classification of Functioning and Disability which emphasizes the rehabilitative approach focusing on the ability to be active and participate.[9] All the presenting problems in the manual are divided into:

  1. Body functions including mental and cognitive functions and problems related hereto
  2. Activities and participation
  3. Context related to the problem.

The manual suggests three levels of advice:

  1. Layperson/health-care assistant
  2. Health-care professional usually nurse in some cases G. P
  3. Physician with the relevant specialty.

Hence, if a person presents with a problem in many settings in particular in low-and middle-income countries the first person he/she encounters when seeking help may typically be a layperson or a health-care assistant with a very basic training. That person will take a history and consider the presenting problem and subsequently find the necessary advice in the manual.

If the problem subsides well and good. However, if the situation aggravates or complications appear the health-care assistant then moves to the next step and refer the individual to a better-qualified health-care professional – very often a qualified nurse. At this level, the nurse will revaluate the condition, getting a more detailed history may be involving relatives, and based upon all data available decide what will be the most appropriate treatment at this level of rehabilitation.

If the problem is still present or even worsened, the next step will be to refer the person to more specialized treatment – if that is available. Again, the situation is revaluated by the more senior health professional and any new information about the treatment provided will be analyzed and based upon all information available proper steps be taken. Using this stepwise rehabilitative model, the specialist resources are used only for cases where less sophisticated interventions have failed to give the required result.

To illustrate how the manual works in practice, depression may be used as an example:

Level 1: Here, you explore the key signs of depression, including low mood, sleeplessness, loss of interest, lack of strength, weight loss, guilt feelings, and lack of energy. The actions to be taken include questions asked about major live events, and supplementary information from relatives and try to psychoeducate them regarding the risk of self-harm.

If the person stops eating and drinking, lies passively in bed or expresses sincere ideas about suicide, it is time to go to level 2.

Level 2: Here symptoms are further explored including self-reproach, agitated behavior, or worrying about serious illness. The first therapy includes to ensure safety, giving advice, or supervision to the health assistant at level 1, informing relatives about safety and self-harm. The second step may be prescribing an antidepressant drug.

If there is no improvement after a month, it may be advisable to refer to level 3.

Level 3: Here, a more comprehensive diagnostic assessment may take place using a structured interview. A shift in choice of antidepressant drug may be advisable and tricyclic antidepressant may be an option. Psychotherapeutic intervention is a possibility, preferably cognitive behavioral therapy.

Like it is the case with the symptom “depression” a similar approach is indicated with other entries.

This field manual has been made freely available as one model of psychosocial rehabilitation applicable in settings with limited resources.[8]

  General Considerations Top

Psychosocial rehabilitation is not always straightforward. Many barriers may make the interventions difficult. Patients may be exposed to stigma in various forms from health professionals, from workplace, etc., as described (e.g.,[10],[11]) Some may lack sufficient support from family and friends which may reduce the likely success of rehabilitation. There may be social challenges, such as homelessness or problems with substance abuse and the presence of comorbidity may make rehabilitative interventions difficult. All this requires that a thorough comprehensive history taking is crucial before initiating the rehabilitation.

In doing so, it is important recalling that populations undergoing psychosocial rehabilitation are not uniform but represent a multifaceted group representing many different backgrounds, for example, geographically, ethnically, socioeconomical. Further that due to the complexity of the clinical situation, adequate psychosocial rehabilitation may require extra resources of workforce and with respect to staff, regular supervision is required as well as training in topics of specific relevance to rehabilitation.

To improve the outcome of psychosocial rehabilitation, robust research data are required analyzing the different models' strengths and weaknesses. With the magnitude of unmet needs short-term rehabilitative interventions should be developed and monitored, and further, there is a need to identify factors of predictive value for successful rehabilitation to identify who will benefit from the intervention.

  Perspectives Top

In the rehabilitative work that lies ahead – as outlined by the WHO[4] emphasis should be given to securing an equitable allocation of resources among all referred to the interventions. Commercialization of rehabilitative care is a risk that should be weighed careful against human values. Further, we have to find the right balance between paying attention to economic aspects and what are the patients interests as well as between the self-determination of the patient on the one side and paying respect to the family and the community on the other. As pointed out by the advisory group of the movement for the global mental health promotion of research is needed to develop affordable and accessible psychosocial rehabilitative services in settings with few resources.[12]

International professional organizations may also have an important role to play. Raising awareness about inequity in accessing services and lobbying to overcome this is crucial as well as promoting the development of rehabilitative service in low- and middle-income countries. This may be done using various means, including exchange programs, educational courses, supporting training and mentoring, and rewriting professional curricula. Launching antistigma programs is essential to overcome barriers in seeking help and developing best practice guidelines with a focus on settings with few resources. Further, there is a need to collaborate with other international organizations and lobby to improve social policies. There is still a long way to go, but as Winston Churchill said “It is not enough that we do our best sometimes we have to do what is required.”

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Conflicts of interest

There are no conflicts of interest.

  References Top

Alma Ata Declaration of 1978. Available from: https://www.who.int/teams/social-determinants-of-health/declaration-of-alma-ata. [Last accessed on 2023 Feb 07].  Back to cited text no. 2
World Health Organization. Rehabilitation 2030 Initiative. Geneva: World Health Organization; 2022. Available from: https://www.who.int/initiatives/rehabilitation-2030. [Last accessed on 2023 Feb 07].  Back to cited text no. 4
Available from: https://www.fagperson.psykiatrien.rm.dk/henvis ning-og-visitation/behandlingspakker/. [Last accessed on 2023 Feb 07].  Back to cited text no. 5
Available from: https://dignity.dk. [Last accessed on 2023 Feb 07].  Back to cited text no. 6
Sjölund B, Harlacher U, Jansen GB, Kastrup M, Madsen AG, Montgomery E, et al. Field Manual of Rehabilitation. Copenhagen: Rehabilitation and Research Center for Torture Victims; 2007.  Back to cited text no. 7
Available from: https://www.dignity.dk/publikationer/. [Last accessed on 2023 Feb 07].  Back to cited text no. 8
Mak WW, Cheung FM, Wong SY, Tang WK, Lau JT, Woo J, et al. Stigma towards people with psychiatric disorders. Hong Kong Med J 2015;21 Suppl 2:9-12.  Back to cited text no. 10
Chandramouleeswaran S, Rajaleelan W, Edwin NC, Koshy I. Stigma and attitudes toward patients with psychiatric illness among postgraduate Indian physicians. Indian J Psychol Med 2017;39:746-9.  Back to cited text no. 11
[PUBMED]  [Full text]  
Available from: http://www.globalmentalhealth.org. [Last accessed on 2023 Feb 07].  Back to cited text no. 12


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Definition and D...
Psychosocial Reh...
Who Benefits?
Global Aspects
Package Model
An Example of Ps...
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