Running head: PSR MODEL/CASESTUDY
Exploring the application of the psychosocial rehabilitation model: A case study
Trina Skinner
Stenberg College
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Exploring the application of the psychosocial rehabilitation model: A case study
This paper will attempt to demonstrate the effectiveness and process where the
psychosocial rehabilitation model is implemented. The essay will consist of two parts. The first
will offer a brief overview of some basic concepts of PSR and how they can prove effective in
psychiatric nursing practice. The second part of this essay will consist of a case study of a mental
health consumer where PSR concepts are applied. A profile of the client will be introduced, a
number of PSR concepts applied that address this client’s personal needs in a context which
follows the format progression throughout the process of assessment, planning and
implementation, and evaluation of the outcomes in terms of effectiveness of this model for the
client. Run on sentence
Where psychosocial rehabilitation in the psychiatric nursing context is concerned, there
are a number of concepts fundamental to the PSR model. Although the nature of the PSR model
is based on a holistic model of health and wellness and therefore can encompass a vast quantity
of perspective concepts, part one of this essay will focus on a few that function at the core of the
PSR model in psychiatric nursing. First a definition and description to increase comprehension of
the nature of PSR will be introduced. This will be followed by a brief overview of the concepts
of, assessment, interventions, recovery, and expressed emotion.
According to the PSR Canada website, “Psychosocial rehabilitation (also termed
psychiatric rehabilitation, or PSR) promotes personal recovery, successful community
integration and satisfactory quality of life for persons who have a mental illness or mental health
concern” (PSR Canada, 2013). PSR is based on a collaborative, client-centered model. PSR
services are individualized, and considered an “essential element of the human services
spectrum” (PSR Canada, 2013). Sundeen, as cited in Stuart (2009), addresses psychiatric
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rehabilitation/PSR as “ a combination of services incorporating social, educational, occupational,
behavioral, and cognitive interventions aimed at long-term recovery and maximization of selfsufficiency” (p. 199).
Proper assessment of the individual, his/her family members, and the community are of
critical importance where PSR is concerned. The assessment process has already begun at the
point of initial contact between the client and psychiatric nurse. I (avoid first person, should state
“this writer”) recognize as a psychiatric nursing student on the IPU that every interaction, no
matter how brief or seemingly mundane, functions as a critical aspect of the assessment process.
My assessment as an RPN student begins when I greet my client at the beginning of the shift. A
font size changes? comprehensive assessment of all three 'parties' is necessary to developing the
effectiveness of contemporary PSR because the individual, the family of the mental health consumer, and
the community all play integral roles that although offer strengths on their own, function in congruence
with one another to create the most optimal PSR environment for care of the mentally ill person (Skinner,
2013).
Planning and implementation of PSR interventions is the next logical step in the progression OF?
a PSR model. Savage, (2009) defines psychosocial interventions as “an umbrella term that covers a range
of therapeutic actions, which are based on a specific understanding of the course and nature of severe
enduring mental illness…[emphasizing] the importance of stress in people’s lives” (p. 29). I was able to
get a firm grasp on this concept while working with a client diagnosed with schizophrenia on the IPU;
this individual became easily agitated and disorganized if he did not have clearly established boundaries
and routine activity throughout the day. If we did not structure the day and establish these boundaries
together, this client would express his agitation verbally and obvious clinical manifestations of his illness
would present (describe them) more frequently. It is critical that during this phase, the psychiatric nurse
aides the individual in developing a treatment plan that promotes the client’s strengths and abilities,
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identifies and makes environmental supports accessible to the client, and teaches the individual basic life
skills to maximize function in the community setting (Sundeen, as cited in Stuart 2009, p. 207).
The nursing treatment plan, according to Sundeen, as cited in Stuart (2009), “should be organized around
very specific behavioral goals that are based on comprehensive assessment of the person’s living skills”
(p. 207).
Recovery is a concept central to the effective PSR model, one that functions as the core of the
psychosocial rehabilitation theory. A most interesting point regarding the concept of recovery, it is based
on objective evidence; actual accounts of mental health consumers regarding their own journey as it
relates to their mental illness. As Repper & Perkins (2003) explain, in contrast to many concepts related
to the mental health field, the concept of recovery from mental illness “did not come from academics and
professionals. Instead, it emerged from the writing of people who themselves’ face the challenge of life
with mental health problems…” (p. 46). The above stated point is that which makes this particular
concept so critical to the procurement of holistic health and wellness. It is the individual themselves who
is ultimately responsible for and able to conceive their journey towards ‘recovery’ from mental illness. It
is in this context that the effectiveness or therapeutic value of the nurse –client relationship comes to the
forefront of quality healthcare.
The concept of expressed emotion originally emanated from the work of a social psychologist in
the 1960’s. The concept of EE developed through researchers findings that persons’ with a diagnosis of
schizophrenia discharged from institutionalized care to resume residence with family members were more
likely to experience relapse than those discharged into the community with no family support (Brown et
al. 1962, as cited in Savage, 2009, p. 30). Development of the concept expressed emotion evolved when
researchers frequently observed font size changes? that “close emotional ties between families
could lead to sub-optimal stimulation and social withdrawal by the patient” (Amaresha &
Venkatasubramanian, 2012, p. 12). EE has therefore become one of the main predicators of
relapse in people with schizophrenia. The authors suggest that proper psychosocial assessment in
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conjunction with interventions that focus specifically on “family psychoeducation can potentially
reduce high EE and relapse of symptoms…” (Amaresha & Venkatasubramanian, 2012, p. 12).
I never fully understood the concept of EE through theoretical coursework. It was not
until I had the opportunity to work with clients diagnosed with schizophrenia on the IPU and
observe symptom recurrence resulting from adverse reactions from family members. There are
two patients in particular that I recall would become agitated and increasingly symptomatic when
engaged in communication with or in regards to matters where family members were involved in
the process of care. I now understand greatly, the significance of the concept of expressed
emotion and its role in PSR.
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Case Study
35 year old ‘Bryan’ is an involuntary committed patient on the IPU with a compound
diagnosis of paranoid schizophrenia with anti-social traits, and poly-substance abuse. Bryan has
a lengthy psychiatric history on the IPU, within the community and in recent years with Forensic
psychiatry (Victoria branch). Bryan had been charged and convicted of criminal mischief
following an episode of relapse in which the RCMP were called after Bryan was reported to be
slashing wildly at the walls and floor of the corridor in his apartment building with a machete.
Bryan is an extremely intelligent individual with substantial university education in the science
and technology field. Bryan was recommitted to the IPU while on ‘extended leave’ after
violating his probation conditions and those of the IPU ‘extended leave’ policy by refusing to
take his medications for a number of days. Vocational history?
Assessment
One day prior to taking on Bryan as a patient on the IPU, I had the opportunity to meet
with him through brief one to one interactions and reflect on his psychiatric history as
documented in his chart. Upon our initial point of contact Bryan presented as calm and pleasant.
I introduced myself and we engaged in casual conversation. Bryan maintained eye contact with
me on all encounters, initially demonstrating an air of confidence and charm, often making jokes
about his popularity with women. During conduction of my mental status assessment (MSE)
with Bryan, he explained that he was not sick, that he had simply stopped taking his medication
because “people had been tampering with it”, and expressed some distress regarding the police
and forensic team punishing him unjustly- that the criminal element to his illness had all been a
PSR MODEL/CASESTUDY
misunderstanding. Bryan would avoid direct questions posed to him and project a question back
onto the person asking. He was reluctant to discuss his confinement to the unit or illness and
management of such on any level other than that of a superficial nature. There was very little
documentation regarding the role of Bryan’s family in his life or advocates in the community.
Bryan expressed delusions of a grandiose nature and would engage in manipulative tactics, such
as ‘staff splitting’ if his desired need was not met promptly. Would appear to confirm the
personality disorder aspect of his dx. The consensus reached by all unit staff was that Bryan’s
treatment plan must be based on strict boundaries and specific organizational tasks in order to
challenge his anti-social behaviors and lack of compliance with the ‘rules’ of the unit.
Planning & Implementation/Interventions
This stage of the PSR model and consideration of specific interventions in Bryan’s case,
hinges on myself assisting Bryan in developing a treatment plan that fosters improved social
interaction skills, functionality within the community setting, relapse prevention, and overall
achievement of holistic health and wellness. Bryan’s overt disregard of staff’s ability to assist
him on his journey of recovery began to lessen when I sat down one morning to suggest that he
formulate a strategic, routine-based plan aimed towards recovery as he viewed it for himself,
with my assistance wherever necessary. The key to the success of this intervention is that Bryan
would be the catalyst for change. I would not be telling him what was conducive to optimal
health for him; rather he would set these perimeters himself, and remain responsible and
accountable for his actions as far as whether or not he adhered to his treatment plan. Good
strategy. Open lines of communication were maintained and it was up to Bryan to address
necessary change and make modifications to his treatment plan as we progressed. Bryan found
font changes? many of the suggested PSR interventions outlined by Savage (2009) applicable to his
treatment plan. Some of these include identification and subsequent reduction of stressors in the Bryan’s
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life, identification of relapse triggers and development of ‘drills’ in which we could attempt to establish
some predictability where Bryan may experience relapse based on mood and behavioral changes, deemed
“relapse signatures”, and establishment of highly structured daily routine (p. 30). Bryan had also
indicated that he wished to regain employment in an IT position pending his health status upon discharge
into the community. He most certainly has the education and experience, which is? I would encourage
him to seek employment through BC employment agencies, free services that help unemployed people
find jobs or offer vocational skills training, which would be another opportunity to focus on improving his
social skills. It was also important that Bryan form two behavior specific goals of treatment: one short
term and one long-term , as a means of measuring progress in the evaluation phase.
Evaluation of outcomes
One way to evaluate the effectiveness of Bryan’s individualized PSR model is to reflect
on goals set at the initiation of the recovery process. Bryan’s short-term goal was to develop
some level of trust in one staff member within one week on the IPU. The long-term goal Bryan
agreed to, learning to differentiate between delusional and reality-based thinking by the time of
discharge. Therefore, a simple evaluation of the level of success with the treatment plan, were
these goals achieved? If not, why? How could we revise the plan to promote optimal success. Is
Bryan compliant with medication? Redirection of Bryan’s delusion that meds are being tampered
with is crucial. Some questions concerned with evaluating effectiveness of the PSR model: Is
this client able to “appraise situations realistically and refrain from projecting own feelings onto
the environment?” (Townsend, 2011, p. 115). Is Bryan willing to ingest food and medication
without demonstrating evidence of suspicion or mistrust? Finally, has the client improved in his
ability to interact and cooperate with staff and peers in the community setting? (Townsend, 2011,
p.115). All of the aforementioned criteria, and arguably the most critical measure of successful
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outcomes, Bryan’s own account of his journey to recovery, are critical points to consider in the
evaluation phase of PSR. Should contain subjective and objective measures
In conclusion, PSR is a valuable model of holistic-based healthcare that offers clients
living with mental illness an opportunity to develop a treatment plan alongside the mental health
team that is based on ones individual needs. A huge benefit of the PSR model, is that it enables
mental health clients to reside in the community and remain responsible, functional members of
society, maintaining a sense of purpose and offering freedom of choice, a basic human right need
we be reminded abandoning the oppressive nature of institutionalization. Nice conclusion
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References
AboutPSRCanada. (2013). Retrieved from
http://www.psrrpscanada.ca/index.php?src=gendocs&link=About
Amaresha, A., & Venkatasubramanian, G. (2012). Expressed Emotion in Schizophrenia: An
Overview. Indian Journal of Psychological Medicine, 34(1), 12-20. http://dx.doi.org/doi:
10.4103/0253-7176.96149
McLoughlin, K., Webb, T., Myers, M., Skinner, K., & Adams, C. (2010). Developing a
Psychosocial Rehabilitation Treatment Mall: An Implementation Model for Mental
Health Nurses. Archives of Psychiatric Nursing, 24(5), 330-338.
http://dx.doi.org.proxy.lib.sfu.ca/10.1016/j.apnu.2009.12.001
Repper, J., & Perkins, R. (2003). Social inclusion and recovery: A model for mental health
practice. London, United Kingdom: Bailliere Tindall, Elsevier Science Limited.
Savage, L. (2009). Introducing cognitive rehabilitation into a psychosocial model of care. Mental
Health Practice, 13(2), 29-33. Retrieved from
http://web.ebscohost.com.proxy.lib.sfu.ca/ehost/detail?sid=2e411635-6989-49af-a451218bc8a759ff%40sessionmgr10&vid=1&hid=20&bdata=JnNpdGU9ZWhvc3QtbGl2ZQ
%3d%3d#db=aph&AN=44796536
Skinner, T. (2013, June 17). Assessment in psychosocial rehabilitation: Week 2 questions.
Forum Post. Retrieved from
http://stenbergcollege.mrooms3.net/mod/forum/discuss.php?d=26442&parent=313983
Sundeen, S.J. (2009). Recovery and Psychiatric Rehabilitation in: Stuart, G & Sundeen, S.J.
(Eds.).Principles and practices of psychiatric nursing 9th Edition. (pp 199 - 216). Mosby:
St.Louis
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Townsend, M. (2011). Nursing diagnoses in psychiatric nursing: care plans and psychotropic
medications (8th ed.). Philadelphia, PA: F.A. Davis company.
Content
Use of valid references (APA style)
Grammar, syntax, sentence structure
Range of Readings
Relevance of material to clinical examples/case study
Critical thinking in assessment, care plan and outcome evaluation
Broad coverage of the major PSR issues with clinical examples & justification
Total
Value
5%
10%
10%
25%
25%
25%
Score
4%
10%
10%
23%
22%
23%
100%
92%
Score out of 30 = 28
Good job Trina. Your paper clearly demonstrates your understanding of the PSR model and your skill in applying its
concepts in the clinical setting. You have presented an interesting case study of a complex client who can clearly
benefit from a PSR approach. I would have liked to see a few more details n your assessment and evaluation (see
in-text comments) Apart from some font size changes several times in your paper, it is well written and formulated. I
enjoyed reading your work.
Donna