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NURSES ROLE IN PSYCHIATRIC REHABILITATION SERVICES
Dr.G Radhakrishnan, Dr.Deepak Jayaranjan, Dr.Krishna Prasad M, Dr.Sivakumar T,
Dr.Poornima Bhola, Dr.Aarti Jagannathan, Dr.Hareesh A, Dr.Sailaxmi Gandhi,
Supported by Dr.Ramachandra N Moorthy Foundation for Mental Health and
Department of Nursing and Psychiatric Rehabilitation Services
National Institute of Mental Health and Neuro Sciences
(Institute of National Importance)
Copy Right: Department of Nursing & Psychiatric Rehabilitation services, NIMHANS,
This e manual is a compilation of the learning material prepared by the subject experts
at NIMHANS (INI), Bengaluru-29 for the National workshop on “Nurses Role in
Psychiatric Rehabilitation Services” conducted on 5th March 2016.
Person suffering with severe and persistent mental illness require rehabilitation along with
necessary and optimized treatment. Psychiatric rehabilitation aims to help these individuals to
develop emotional, social and intellectual skills needed to live, learn and work in the
community. The refinement of psychiatric rehabilitation has achieved a point where it should
be made readily available for every disabled person.
Nurses play a vital role in assisting individuals with disability and/or chronic illness to attain
and maintain maximum function. The rehabilitation staff nurse assists clients in adapting to
an altered lifestyle, while providing a therapeutic environment for client's and their family's
development. The rehabilitation staff nurse designs and implements treatment strategies that
are based on scientific nursing theory related to self-care and that promote physical,
psychosocial, and spiritual health.
It is a great pleasure for Department of Nursing, NIMHANS, to organize a National
Workshop on “Nurses Role in Psychiatric Rehabilitation Services” on 5th March 2016 to
equip Nurses with necessary knowledge and skills regarding Rehabilitation services. A
compilation of all the sessions in the workshop is getting released as an e-manual for further
We hope this workshop provides a platform for Multidisciplinary Mental Health team
members to share their Knowledge, ideas, and expertise, with the goal of promoting
professional development of Nurses. They can then utilize this information to improve the
quality of Rehabilitation services wherever they serve in future.
Additional Professor& Head
Department of Nursing
“Gratitude is not only the greatest of virtues but the parent of all others”-Cicero.
We are deeply indebted to Dr.B.N.Gangadhar, Director and Vice Chancellor, NIMHANS, for
his keen interest, administrative support and especially his valuable time in meticulous
review of the scientific content of this material.
We express our heartfelt gratitude to the Registrar, Dr.K.Sekar for his constant administrative
support throughout this venture.
We extend our extreme gratitude to Dr.S.K.Chaturvedi, Professor and Dean of Behavioural
Sciences, for his constant guidance and support for the workshop.
We are extremely thankful to Dr.Ramachandra N Moorthy Foundation for providing financial
support for the successful completion of the workshop
We are grateful to Dr.Ramachanda, Additional professor & Head, Department of Nursing and
Dr.Jagadisha Thirthahalli, Professor and Head, Psychiatric Rehabilitation Services for their
unlimited support and encouragement throughout this strive.
We profusely thank all the resource persons for their enthusiasm, constant support,
involvement and for sharing their knowledge and expertise in their respective fields with the
We would like to appreciate the constant support and in depth participation of all faculty and
team members of Department of Nursing and Psychiatric Rehabilitation Services, NIMHANS
which resulted in the successful completion of this workshop
We thank Dr. Naveenkumar, Associate Professor of Psychiatry for his valuable suggestion in
the completion of this manual
We thank Dr.Mathew Varghese, Professor& Head, Department of Psychiatry for offering
Arts Theatre to conduct the workshop.
We appreciate Mrs. Natasha Thomas, PhD Scholar Department of Nursing, for her efforts
and support for the workshop and for compilation of the e-manual.
We are grateful to the Heads of all Institutions who have permitted their faculty and staff to
be a part of this workshop and we wholeheartedly thank all the participants who took pain to
come here in midst of their busy schedules to attend the workshop.
It is our pleasure to express our heartfelt thanks to the Department of Mental Health
Education, for capturing the colors of this venture through their inimitable photography.
We thank all office staff, Department of Nursing, for their interests and inputs in different
stages of the workshop.
We thank almighty for his blessings.
Assistant Professor of Nursing& Organizer of the Workshop
Mental Illness –Acute and Chronic
Nature of Mental Illness
Dr. Krishna Prasad M
Mental Disability and its Assessment
Dr. Deepak Jayaranjan
Psychiatric Rehabilitation Services-
Meaning, Principles, its therapeutic
implications and importance
PRS Team-Roles and responsibilities
of Psychiatric Rehabilitation Services
Mobilizing Resources for Psychiatric
Rehabilitation Services, Involving
Infrastructure and facilities required
for Psychiatric Rehabilitation services.
Ideal set up for psychiatric
Rehabilitation services in a General
Domestic Skills Training and its
Nurses Role in Psychiatric
Mental Illness: Acute and chronic nature of mental illness
Krishna Prasad M., MD., Associate Professor of Psychiatry (Psychiatric Rehabilitation)
NIMHANS, Hosur Road, Bangalore -560029, Email: email@example.com
What is mental illness?
Mental illness can be simply defined as “any illness experienced by a person which affects
their emotions, thoughts or behaviour, which is out of keeping with their cultural beliefs and
personality, and is producing a negative effect on their lives or the lives of their families”
Why should we be concerned?
Mental illnesses are common and are a source of major public health problem. They can be
very disabling and can also cause premature mortality. Mental health services are not
adequate in our country. The symptoms of the illness can be very stigmatizing to the sufferer
and family. Importantly treatment is achievable and relatively inexpensive.
What are the types of mental illnesses?
ICD-10 and DSM V provide the latest classification of mental illnesses. A simple
classification of mental illnesses could be as follows
• Common mental disorders (depression, anxiety)
• Severe mental disorders (psychotic illnesses such as schizophrenia, bipolar disorder)
• Substance use disorders
• Mental retardation
• Mental disorders in the elderly (dementia, depression)
• Mental disorders in children for e.g. ADHD, Learning disabilities
• Organic mental disorders
Onset of mental illnesses can be abrupt, acute or insidious
Mental illnesses are usually detected based on history and interviewing patients and
What are the causes of mental illnesses?
The following factors may be responsible for mental illnesses:
Brain diseases and pathology
Stressful life events
Contextual factors - Difficult family situations
Other medical conditions
Chronic mental illnesses as non-communicable diseases
There are many similarities with conditions such as diabetes mellitus or hypertension for
chronic mental illnesses. They are slowly progressive and of a chronic nature with relapses,
hence needing long term care.
Culture and mental illness
Culture may influence the way mental illnesses are understood. The explanatory models may
vary between cultures. Culture may also mould presenting symptoms. Different cultures may
have different words or idioms to describe emotional distress. Culture may also determine
pathways to care, treatment and help seeking. Stigma is another important factor that may
vary with culture.
Course of mental illness
Schizophrenia - the following courses may be observed
1. Complete recovery without relapse
2. No relapses but with residual symptoms
3. One or more relapses with complete remissions
4. One or more relapses with incomplete remissions
5. Continuously psychotic
Mood disorders may present with a single episode or may be recurrent. There may be
incomplete remissions in between episodes or the episodes may be chronic in nature. Anxiety
disorders may present as discrete attacks as in panic disorder with anticipatory anxiety,
follow a waxing waning course as with obsessive compulsive disorder or may be continuous.
Following modalities may be used
Drugs: antidepressants, mood stabilizers, antipsychotics, anxiolytics or hypnotics
Psychotherapy for e.g. cognitive behaviour therapy
Electroconvulsive therapy may be needed in severe cases
• Mental illnesses are common and can be disabling
• Mental illnesses can occur acutely or insidiously
• Often they follow a chronic course
• Chronic mental illnesses are similar to other Non-Communicable Diseases
• Treatment is usually multidisciplinary and even be multi sectoral
• Treatment refractoriness is noticed in some patients
• Mental health services need to be recovery oriented
Mental Disability and Its Assessment
Dr. Deepak. Jayaranjan., Asst. Professor of Psychiatry (Psychiatric Rehabilitation)
NIMHANS, Hosur Road, Bangalore -560029
Disability is an umbrella term that is defined by the International Classification of
Functioning, Disability and Health (ICF). It includes under its rubric,
- impairment suffered due to an illness, e.g. anxiety caused due to panic attacks in panic
- activity limitation, e.g. inability to travel due to fear of having such attacks
- participation restriction, e.g. not being able to form social relationships due to being house-
bound and other people’s reactions to this
This is an acknowledgement that every human being may experience some degree of
disability in their life through a change in health or in their environment, and adopts a
biopsychosocial approach to the concept of disability.
Figure 1. Taken from World Health Organization. Towards a Common Language for
Functioning , Disability and Health ICF (1)
In India, the major laws governing disability are
- The Persons with Disabilities (Equal Opportunities, Protection of Rights and Full
Participation) Act, 1995 (PwD Act)
- The Rehabilitation Council of India Act, 1992
- The National Trust Act, 1999 (covering autism, cerebral palsy, mental retardation and
- The pending Rights of persons with disabilities bill-2014
The term mental disability has been used to include both disorders of intellectual
development as well as the group of disorders included under the category of mental illness
in the Census previously. "Mental retardation" means a condition of arrested or incomplete
development of mind of a person which is specially characterized by sub normality of
intelligence, as per the PwD Act, 1995. Mental illness has been recognized as one of the
disabilities under Section 2 (i) of the Persons with Disabilities (Equal Opportunities,
Protection of Rights and Full Participation) Act, 1995. "Mental illness" has been defined
under Section 2(q) of the said Act as any mental disorder other than mental retardation. Both
developmental disorders and mental illnesses (which include substance use disorders) cause
significant and chronic impairment in functioning, activity limitation and participation
restrictions. Disability is significantly influenced then by the severity of the disorder and the
contextual/ environmental factors, which could enhance or impair functioning. Persons with
mental illness experience fluctuations in severity, which means that disability can be
alleviated when a person is better, and it is exacerbated when a person has worsening of
illness/ episode of illness.
It's important to remember that persons with intellectual disability can have improvements in
their adaptive functioning over time, but essentially they would require varying degrees of
support over their lifetime, depending on how severe the developmental disorder is. They
may develop other medical conditions and have other developmental or psychiatric co-
morbidities which would add to their disability burden. Hence, disability can be lessened by a
number of interventions including health promotion, treatment of specific disorders,
empowering family members, educational supports, welfare benefits (including financial aid,
reservations for education and jobs, etc.) , efforts to reduce stigma apart from a whole host of
individual aid, community and policy measures.
The group of disorders related to mental illness and substance use disorders are among the
largest contributors to the world's burden of years of life lost due to disability (YLD), a
component of disability adjusted life years (DALY). In terms of DALYs, of which the other
component is years of life lost (YLL), they form the fifth largest. Countries across the world
have recognized that mental illness carry the burden of disability, and so does the UNCRPD
(United Nations Convention on the Rights of Persons with Disability,2006) to which India is
For intellectual developmental disorders (IDD), also known as mental retardation, the
quantification for the same is done via a testing of Intelligence Quotient (IQ), based on which
disability is measured. It is important to remember that the IQ test is an approximation of
intellectual functioning, but ideally clinical judgement should be used to interpret these in the
context of actual adaptive functioning and behaviour. In terms of IQ scores, the following is
put forth in the Ministry of Social Justice notification in the Gazette of India, 2001,
IQ Level Disability %
Between 70 - 89 25% (borderline intelligence)
Between 50 - 69 50% (mild intellectual disability)
Between 35 - 49 75% (moderate intellectual disability)
Between 20 - 35 90% (severe intellectual disability)
< 20 100% (profound intellectual disability)
A disability certificate for mental retardation should be issued by a Medical Board
consisting of three members duly constituted by the Central/State Government. At least, one
shall be a Specialist in the area of mental retardation, namely psychiatrist, paediatrician and
clinical Psychologist. For individuals less than 18 years of age, the certificate must be
temporary, though it can be issued as permanent for those above the age of 18. (2)
The previous presentation has touched upon the dynamic challenge mental illnesses
provide, with their chronic nature being compounded by acute exacerbations. Disability for
those with mental disorders is less easily quantified because of their dynamic nature and due
to the lack of obvious physical stigmata. In the face of this, the tool used across India to
quantify the extent of disability is the Indian Disability Evaluation and Assessment Scale
(IDEAS), developed for this purpose by the Rehabilitation Committee of the Indian
Psychiatric Society in 2002. While the assessment itself is carried out by a mental health
professional, the certification should be carried out by a Medical Board comprising of the
following members, of which at least two of the members, including Chairperson of the
Board, must be present and sign the disability certificate –
- The Medical Superintendent/Principal/Director /Head of the Chairperson Institution or his
- Psychiatrist Member
- Physician Member
The IDEAS scale has 4 dimensions, each with a score based on severity of
impairment in that dimension from 0 to 4 points. This is usually done by interviewing and
examining the person with illness, the care-giver and the reviewing of any case records, if
-Self-care: guided by social norms and conventions and including aspects of hygiene, eating
habits and maintenance of their own belongings
-Interpersonal activities (Social Relationships): including patient's response to questions,
requests and demands of others; regulating emotions; initiating, maintaining and terminating
interactions; and engaging in physical intimacy
-Communication and Understanding: including understanding spoken, written and non-verbal
communication, as well as ability to interpret and communicate with others
-Work: including employment, housework and educational performance
It also scores the dimension of “duration of illness”, as follows,
< 2 years: 1 point
2 - 5 years: 2 points
6 - 10 years: 3 points
> 10 years: 4 points
The composite score would be made by adding the 4 dimensional scores and the score based
on duration of illness. (2) The maximum score on this scale is 20. The overall score and
percentage would be used to quantify disability, with scores of 40% (> 6 / 20 on the IDEAS
scale) and over qualifying for disability benefits in India. The certificate issued should
specify whether it is a temporary or permanent certificate. For disorders in which change in
status may occur and where individuals are below the age of 18 years, a temporary certificate
can be issued. There exist other scales to assess disability such as the WHODAS (WHO
Disability Assessment Schedule), which looks at a few more dimensions than the IDEAS,
such as the mobility and participation in community activities dimensions. Autism is a
developmental disorder that has no officially identified scale to measure its severity as of yet,
though clinical scales like the Indian Scale for Assessment of Autism (ISAA) exist.
Multiple disabilities refers to a combination of two or more disabilities as defined in clause
(i) of Section (2) of the PwD Act, 1995, including
Locomotor disability including leprosy cured
Speech and hearing impairment
The formula for calculating the total amount of disability for multiple disability is a + b (90-
a)/90, where a is the percentage of disability of the more disabling illness. For example, in the
case of a child with mild intellectual disability and low vision, if the percentage of intellectual
disability is 50% and visual disability is 20%, then by applying the combining formula given
above, the total percentage of multiple disability will be calculated as follows: -
50 + 20(90-50)/90 = 58.88 %
1. World Health Organization. Towards a Common Language for Functioning ,
Disability and Health ICF. Geneva; 2002.
2. Acts & Guidelines - Guidelines for Mental Illness: Office of the Chief Commissioner
for Persons with Disabilities, Government of India. (2016, February 28).
Psychiatric Rehabilitation Services – meaning, principles, and its therapeutic
implications and importance of Psychiatric Rehabilitation Services
T Sivakumar, Assistant Professor of Psychiatric Rehabilitation, Department of Psychiatry,
NIMHANS, Hosur Road, Bengaluru-560029
Rehabilitation enables a person disabled by a psychiatric disorder to achieve his/her life
goals. Life goals are unique to a person’s life situation and aspiration. A person’s life goals
may include having friends, getting a job, learning to sing, being respected by others and
being independent. Thus, scope of rehabilitation extends beyond employment.
Psychiatric rehabilitation is a discipline utilizing set of strategies/ techniques to meet needs of
persons disabled due to mental retardation and mental illness.
Goals, values and guiding principles of Psychiatric Rehabilitation
2. community integration
3. quality of life
1. self-determination and empowerment
2. dignity and worth of every individual
3. optimism that everyone has the capacity to recover, learn and grow
5. cultural diversity
6. promotion of valued social roles and normalized environments
C. Guiding principles
1. person centred approach
2. partnership between service provider and service user
3. partnership with family members and significant others
4. utilization of peer support
5. utilization of natural supports
6. strengths focus
7. focus of work and career development
8. assessments related to person-chosen goals and environments
9. emphasis on goal related skills training, resource development, and
10. integration of treatment and rehabilitation services
11. ongoing, accessible, and coordinated services
12. empirical orientation
Where should Rehabilitation be done?
Many think that rehabilitation is done in hospital or in specialized rehabilitation centres.
Ideally, rehabilitation should occur in the community where the person resides. A community
based approach facilitates community reintegration of the concerned individual. When
community sees a person with mental illness regain valued social roles and contribute to
society, it shatters many myths and misconceptions about mental illness.
World Health Organization (WHO) promotes Community based Rehabilitation as a strategy
to improve access to rehabilitation services for Persons with disabilities (PwD) in Low and
Middle Income Countries(LAMICs). WHO has developed a CBR matrix which consists of
five key components: health, education, livelihood, social and empowerment.
Fig 2 taken from WHO, CBR Guidelines
Recovery: the emerging paradigm
Recovery encapsulates hope and challenge in Psychiatric rehabilitation.
Anthony (1993) defined Recovery as a deeply personal, unique process of changing one’s
attitudes, values, feelings, goals, skills and/or roles. It is a way of living a satisfying, hopeful,
and contributing life even with limitations caused by the illness. Recovery involves the
development of new meaning and purpose in one’s life as one grows beyond the catastrophic
effects of mental illness.
Each person’s road to recovery is unique.
Rehabilitation assessment & intervention
Unlike diagnostic assessments which focus on eliciting symptoms and deficits, rehabilitation
assessment is aimed at understanding the lived experience of mental illness. The strengths of
the person, family and environment are assessed. In discussion with the family, the
rehabilitation professional helps the person with psychiatric disability prioritize life goals.
Subsequently, the person with psychiatric disability is assisted in preparing a plan to achieve
the life goals. Execution of the plan requires fruitful coordination between different
stakeholders like family, friends, neighbours, teachers, employers, NGO’s, colleagues at
workplace and mental health professionals.
Nature of rehabilitation inputs vary widely according to strengths and priorities of the person
with disability. A person who could not complete college education may need help in joining
a course according to interest, ability and availability. A homeless mentally ill person will
need safe shelter, treatment, tracing family address and reuniting with them. A person
unemployed due to stigma of mental illness will require job placements according to abilities
and qualifications. Some may need training in livelihood options.
The most important pre-requisite for success is ‘perceived need for change’ on part of the
person with psychiatric disability. Unless the person is ‘rehabilitation ready’, the
interventions are unlikely to be successful. The therapist needs to be non-egoistic, persistent,
innovative, flexible and optimistic in the recovery journey. An experienced therapist
understands that one can only assist in the process of rehabilitation and cannot forcefully
rehabilitate a person against their wishes.
The rehabilitation process is a slow journey of building upon incremental benefits accrued
over a period of time. Therapeutic relationship, hope for a better tomorrow and ability to
learn from failure are vital ingredients.
There is a need for transforming mental health services from current focus on treatment of
symptoms and crisis intervention to helping people lead meaningful lives in their
1. Pratt CW, Gill KJ, Barrett NM, Roberts MM. Psychiatric Rehabilitation. Third
Edition. Academic Press, Elsevier. 2014.
2. Sivakumar T. Psychiatric Rehabilitation: A new dimension in holistic care. MINDS
Newsletter. February 2015.
3. Psychiatric Rehabilitation Services, NIMHANS. Pamphlet on ‘FAQ’s in Psychiatric
4. World Health Organization. Community-based rehabilitation: CBR guidelines. 2010.
ISBN 9789241548052. Available at
Accessed on 11 August 2014.
Working in a Multidisciplinary System: Roles and responsibilities of Psychiatric
Rehabilitation Services Team members
Dr. Poornima Bhola., Associate Professor, Department of Clinical Psychology
& member of the Psychiatric Rehabilitation Services Team, NIMHANS, Bangalore – 560029
“Alone we can do so little, together we can do so much ~ Helen Keller
This well-known quote exemplifies how work should ideally be organised in
multidisciplinary psychiatric rehabilitation settings. The synergistic power of a rehabilitation
team working together can accomplish more than separate members operating in a
disconnected manner. The shift to a recovery-oriented perspective, which values functioning,
social integration and positive involvement of the consumer, means that the number of
stakeholders have increased.
The narrow view of a multidisciplinary team as comprising of psychiatrists, clinical
psychologists, psychiatric social workers, nurses and occupational therapists has expanded to
include both the voice and contributions of consumers, their families, non-governmental
organisations and even volunteers.
Role of psychiatrist
Formulate rehabilitation plan
Bring new research findings to the team’s attention
Model practice based learning
Role of clinical psychologist
Identification of the profile of strength and deficits
Planning comprehensive interventions
Quantifying disability for government benefits and tracking progress
Psycho social interventions (skills training, family psycho education, education and
training, cognitive behavioural therapy, behavioural interventions
Role of Psychiatric social workers
Social analyst (assessment of patient, family, his skills and environment, making
social diagnosis, analyse and plan interventions accordingly)
Case worker (helping people individually to meet psycho social, family and
Community organization professional
Networking and Liaison officer
Social work administrator
Role of vocational/occupational Therapist
Assess strengths and weakness of patients and select vocation accordingly
Train, guide and supervise the work
Members of each discipline have their unique strengths and resources, specific training
backgrounds and thereby, unique contributions to make to planning and running
rehabilitation services. Each member has core tasks as well as liaison and collaboration role
with other team members.
The difference between a ‘multidisciplinary’ approach and an ‘interdisciplinary’ perspective
is important to understand. Rehabilitation teams must work to reduce any obstacles stemming
from ambiguity and conflict over roles; conflict and confusion over leadership; differing
understandings of clinical responsibility and accountability and interprofessional
The presentation will focus on the roles and responsibilities of key team members. We will
also discuss the contextual realities in India; manpower shortages, limited rehabilitation
resources, practical barriers, and inadequate emphasis on rehabilitation and recovery. These
factors may call for flexible ‘task shifting’ in situations when rehabilitation teams lack
member/s from a particular discipline.
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Basvarajappa, P.C.A. Ahamed, G. Desai & S.K. Chaturvedi. Nuts and Bolts of Starting and
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P.C.A. Ahamed, G. Desai & S.K. Chaturvedi. Nuts and Bolts of Starting and Running
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services. Aust N Z J Psychiatry. 2002 Feb;36 (1):75-80.
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teamwork in psychiatric rehabilitation. Psychiatr Services. 2001 Oct; 52 (10), 1331-1342.
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are we in 2013? Journal of the American Psychiatric Nurses Association, 19(3), 113-116.
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Smith, G.B., Schwebel, A.I., Dunn, R.L., McIver, S.D. (1993). The role of psychologists in
the treatment, management, and prevention of chronic mental illness. American Psychologist,
Sujai R, Ahamed PCA, James JW, Basvarajappa C. Role of Social Workers, Lay health
Workers and Voluneteers in Psychiatric Rehabilitation Services. In C. Basvarajappa, P.C.A.
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Rehabilitation Services. 2016. NIMHANS Publication No. 115.
Mobilizing Resources for Psychiatric Rehabilitation Services Involving
Volunteers and NGO's
Jagannathan A*, Shanivaram Reddy K**
Liberalization, privatization and globalization (LPG) of mental health care has caused: (1)
rise in the costs of medication and mental health care treatment and (2) brain drain of mental
health professionals from India resulting in poor ratio of mental health professionals vis-a-vis
patients. Institutional based Psychiatric Rehabilitation is often resource intensive. In this
context, Family Based Rehabilitation (FBR) and Community Based Rehabilitation (CBR)
have been advocated as an alternative by the World Health Organization and in the recent
drafts of the Government of India – Mental Health programmes. However, to successfully
rehabilitate patients their families and in the community, networking and liaisoning is very
important. In this context, mobilizing resources especially by involving volunteers and Non-
Governmental Organizations (NGO’s) who work in grassroots level, is important. In this
session, we shall understand the various activities in which mobilizing volunteers and NGO’s
would be useful in the field of psychiatric rehabilitation.
Non-Governmental Organizations (NGO’s):
NGOs often work at grassroots levels and know the community well. Families living the
community are also comfortable to work with them due to their presence and support in the
community. Hence it is often better to liaison and network with a local NGO to help in the
process of psychiatric rehabilitation. Some of the resources that can be mobilized by
networking with local NGOs are:
1. Community resources for vocational rehabilitation: Some communities are agrarian
and other focus on diary or poultry. Based on the focus of the community and the
availability of resources in the community, vocational skill training can be provided to the
recovered person with psychiatric disability, so that he can return back to his community
and be productive. Local NGO’s can help assess the vocational potential of the person
with mental disability and match it with community resources available to help successful
2. Community people as resources for Social Action: Empowered groups of caregivers
can be encouraged towards social action when required including fighting for the rights of
persons with MI and forming micro-finance self-help groups for financial sustenance. The
local NGO can help create and facilitate such groups.
3. Community health systems for continued services: Due to logistic reasons, a number
of patients and caregivers are unable to frequently approach a tertiary care hospital for
treatment and rehabilitation services. In such a case, a local NGO in the area, could help
either provide continued support in form of networking with district psychiatrists for
treatment, providing psychosocial rehabilitation inputs such as information on welfare
schemes, vocation rehabilitation options in the community etc.
4. Building Community Support: Empowering local stakeholders like caregivers, local
health professionals and key persons in the community such as teachers, religious heads,
and local administrators can help create a positive regard for inclusion of persons with MI
in the community. Further this group if favourable could help to spread positive
awareness about inclusiveness of persons with mental illness in nearby communities.
Local NGO’s could act as catalyst to initiate some of these activities.
Roles of Volunteers:
Writing from experience, at the Psychiatric Rehabilitation Services (PRS), National Institute
of Mental Health and Neurosciences (NIMHANS), a tertiary care hospital for continued
psychiatric care volunteers have been mobilized for the following roles to aid in the process
1. Fund Raising: Volunteers have often helped in collecting funds for treatment of poor
patients or for buying of necessary equipment’s and medications for the persons with
mental disability from lower socio-economic background.
2. Conducting classes: Volunteers have been involved in taking yoga classes, computer
classes and art classes weekly for persons with mental disability at the PRS. Here the
volunteers commit to certain time schedules in a week, when the classes are held as
part of the activities of PRS, NIMHANS.
3. Vocational Rehabilitation: Volunteers have helped place persons with mental
disabilities in jobs in companies run by them or in places known to them. This is done
through the process of identifying a candidate suitable for the job profile and the
volunteer or his significant other holding a recruitment interview.
4. Conducting recreation activities: A few volunteers have been helping out in
conducting the weekly recreation activities at PRS which both persons with mental
disability and families look forward to.
Local volunteers are often enthusiastic to get enrolled in volunteering activities in PRS, and it
has been noticed that volunteers come up with varied ideas as to how they can be utilized, i.e:
for marketing products, for helping them write up resumes for job interviews, for conducting
social events etc. They can hence be mobilized as effective resources and as part of the
psychiatric rehabilitation team, especially in teams where there is paucity of skilled
NGO’s and volunteers are both important resources in the process of psychiatric
rehabilitation. Often skilled rehabilitation professionals, who are few in number, are able to
provide mainly institutional based rehabilitation and have to rely on the local level NGO’s
and volunteers to provide continued support to the person with mental disability in the
community. In this context, it is essential for any tertiary care centre or an institutional
rehabilitation service to develop good networks with volunteers and NGO’s in the community
who can continue the rehabilitation efforts in the true sense: ‘Re-habilitate’ – help reinstate
the person with mental disability in his habitat.
*Assistant Professor of Psychiatric Social Work, Psychiatric Rehabilitation Services (PRS),
National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru -
**Psychiatric Social Worker in Psychiatric Rehabilitation Services, Psychiatric
Rehabilitation Services, NIMHANS, Bengaluru-560029
Infrastructure and facilities required for Psychiatric Rehabilitation Services. Ideal
Setup for Psychiatric Rehabilitation Services in a general hospital - Physical lay out
Dr. Hareesh Angothu, Assistant Professor of Psychiatry, Psychiatric Rehabilitation Services
E mail: firstname.lastname@example.org
What constitutes psychiatric rehabilitation in persons with mental illness?
A simple way to understand is that many people with severe mental illnesses can have
difficulties in self-care, maintaining good social interactions, maintaining good interpersonal
relations, getting jobs of their choice, and in sustaining jobs by meeting expectations. A
process wherein the person with mental illness would be supported across these areas apart
from any other patient specific needs would constitute psychiatric rehabilitation.
Rehabilitation of persons with severe and chronic mental illness is quite distinct from the
rehabilitation of persons with physical disabilities. Needs of person with physical disabilities
can be more or less similar throughout life, as their physical handicap tends to be a fixed one.
In persons with mental illnesses, the severity of illness can fluctuate and hence resulting in
dysfunction. This often leads to change in rehabilitation needs for persons with mental illness
over a period of time.
Concept of ideal psychiatric rehabilitation
As the rehabilitation needs of persons with mental illness can change over a period of time,
an ideal psychiatric rehabilitation set up to changing needs of persons with mental illness
throughout their life.
What are the goals of psychiatric rehabilitation?
As I said earlier, rehabilitation needs in persons with mental illness can differ significantly.
Goals should be set on a case by case basis and also goals can change over a period of time in
the same person. Identifying the unmet needs of a person with mental illness and working out
strategies to achieve those goals with the consensus of patient, his caregiver, in liaison with
the available government and non-government resources.
A person with acute excitement or aggressive or suicidal behavior requires intensive
treatment and hence appropriate treatment is the goal. Once the patient is stable, a
reassessment of unmet needs should be done. A stage by stage assessment of unmet needs of
the patient and providing an appropriate support so that patient can lead an independent,
productive and satisfactory life.
Setup for a Psychiatric Rehabilitation
Such holistic approach requires a multi-disciplinary team approach consisting of psychiatric
nurses, social workers, community psychiatric health workers, case managers, psychologists
and psychiatrists. Given the scarcity of above mentioned professional resource persons, a
multi-disciplinary team in which members work on a part time basis also might be as
effective as a team with constant members. Apart from the above mentioned team of
personnel, patients might require a day care center, supported employment opportunities, half
way homes, and long stay homes depending upon their severity of illness and social support
available to them.
Set up for psychiatric rehabilitation in a general Hospital
It depends upon the available space, available staff at a particular hospital, number of
mentally ill patients attending such hospital, background of majority patients and finally and
most importantly it depends upon the budget that can be allocated towards such set up. A
simple day care center with recreation facilities and 1 or 2 sections like horticulture with in
the hospital premises and or with tailoring section could be considered with very less
What is a Day care center for persons with mental illness?
A day care center is any place where persons with mental illness can be engaged during day
time. This can be inside the hospital premises like as in NIMHANS or can be situated distant
What does a day care center contain and how does it help?
Depending upon the available space, available rehabilitation team members and budget, it can
contain many sections where even people can get trained or it can be simple small room
where in persons with mental illness can just attend during day time for recreation and
spending time. Day care centers help patients in developing good work habits. If day care
centers contain facilities for training and if skilled trainers are available, then patients can
learn even new skills which can be useful for their job opportunities.
How does the day care center at NIMHANS help person with mental illness?
Day care center at NIMHANS is a part of Psychiatric Rehabilitation services and it contains
many sections like Tailoring, Computer, Library, Bakery, Weaving, Domestic skills training,
Crafts, Printing, Horticulture, Carpentry, Arts and Candle making. Persons with mental
illness attend here mainly for engagement during day time and to develop good work habits.
During the process of engagement, a comprehensive assessment of rehabilitation needs would
be done by the team of Psychiatric Rehabilitation. An initial assessment at the time of
enrolling as a day boarder would be done by the team and a periodic review of unmet needs
and strategies would be discussed with the patient and his caregiver.
How much it costs to set up a day care center at General Hospital?
It again depends upon available space and manpower and more importantly the background
of patients attending the hospital for rehabilitation.
A simple Recreation Room might require a small to large room with some magazines, play
material, Television. It can be arranged even by collecting old items from donors. It may
require a Psychiatric nurse or Social worker who can just interact with patients attending that
room, looking after their medication and encouraging them to spend their day time at such
facility till they get involved in some occupation.
Horticulture Section: It may not require many funds. Some open but protected place for
farming with in the hospital premises with water facility would be just good. From few
hundreds to few thousands might be required for getting agricultural instruments and to buy
Tailoring section: Every hospital usually will have a tailor section to meet the needs of
Hospital and they can be involved. Interested patients can learn tailoring skills which
sometimes may help them in getting jobs in garments related jobs or to set up own with
Candle making Section: Cost of Aluminium Moulds would cost around 5000/., depending
upon model. Regular Wax, threads, stove, a minimum of 200-300 SFT room might be
required. A trained instructor would be required to engage patients and to teach them.
Manufactured candles can be sold at Hospital or can be marketed however sometimes
marketing can be challenging.
Bakery section: Machinery might cost around 2-3 Lakhs of Rupees and its maintenance
requires trained staff. However, Bakery section can be self-sustaining and sometimes profit
making as it can meet all the demands of hospital patients for Bread, Biscuits etc.
Library Section: A small room with books, newspapers and magazines can be simple to start
provided space is available. You may get many donors who can donate books.
Several other sections like crafts, weaving, bamboo product making, Printing and
Photocopying section, Domestic Skill training, Yoga section, Section for Physical exercise,
section for computer learning, arts learning can be considered depending upon available
resources like budget, space and skilled trainers.
What if psychologist, social worker and skilled trainers are not available?
If budget and skilled trainers are an issue to set up rehabilitation day care center, then it
would be better to establish networking with local NGOs, local employers who would be
willing to take up the persons with mental illness for semi-skilled and unskilled Jobs. To
obtain good results with psychiatric rehabilitation services, a team should at least contain
social worker who can establish networking with local resources and guiding the patients to
such resources, along with psychiatrist and psychiatric nurse who can look after the medical
needs of the patient. Even if social worker is not available, a psychiatrist or nurse can share
the social worker role by trying to establishing networking with local resources.
Some of the following questions should be addressed before any rehabilitation set up is
1. How many mentally ill patients do attend to your hospital?
2. How many mentally ill inpatients do you have on average in your setup?
3. Do you have a regular psychiatrist and a regular supply of medication?
4. Does your setup have any social worker available?
5. Do you have adequate nursing staff to look after if a day care center is started?
6. Do you have some space to be allotted for a day care center with in your or very near
to your setup?
7. 7 Do you have some funds or budget which can be allotted to starting certain
8. Does your hospital and setup have easy access to patients in terms of local transport?
Answering the above questions will provide a clue about what kind of rehabilitation
setup would be required and what can be done. To those who would like to start new
sections as part of their day care center, NIMHANS day care center provides a good
opportunity to observe and learn the issues involved in such day care center. A simple
narration of setup and one-time observation might not be sufficient to understand the
difficulties. Those who are serious in establishing a day care center at their work place
can be in touch with our team.
Domestic skills Training and its therapeutic values
Dr. Sailaxmi Gandhi, Associate Professor of Nursing, NIMHANS
Introduction: Activities of daily living (ADL) are tasks or activities done on an everyday
basis by people routinely, and these are needed to enable the person to live independently.
BADL (Basic activities of daily living) are those activities performed when one awakens in
the morning and gets ready for the day. IADL (Instrumental activities of daily living) are the
instrumental activities of daily living that indicate ability to exist independently. These are
also known as independent living skills.
What are domestic skills? Domestic Skills (DS) would constitute the IADL part of ADL.
These would include all activities done to maintain a house-hold inclusive of the kitchen.
Presence of these skills decrease the person with mental illness (PwMIs’) dependency on
significant others in their lives. Although mankind has been endowed with these skills since
the time of Adam and Eve, not many of us think about the value of these skills especially for
persons with mental illness. Caregivers including mental health professionals are very much
concerned with positive symptoms such as hallucinations, delusions, aggression and
wandering behaviour. Deficiency or lack of DS in a person who was pre-morbidly otherwise
is part of the negative symptoms of the illness. In a busy OPD, mental health professionals
rarely talk about rehabilitation at the time of first contact (detailed work up) whereas ideally
this would be the best time to start focussing on this.
Who are the benefiters? It is not only the PwMI who benefits but also caregivers and
mental health professionals.
What are the therapeutic benefits of DS training for the PwMI? Some of these are listed
out beneath and briefly discussed.
1. Increase in self-esteem and subjective well-being (SWB): When a domestic chore is
done and done well it draws attention and praise from the family members. This
naturally boosts self-esteem i.e. the regard which the PwMI has for himself or herself
which promotes their mental health. A healthy self-esteem contributes directly to
one’s subjective well-being.
2. Increase in social cognition: The ability to recognize body language and facial
expression is important as these convey approval or disapproval. The pleasure
experienced when completed tasks meet approval encourages the PwMI to understand
significant others body language and facial expressions which strengthens social
3. Increase in social skills: Gradually, PwMI starts interacting with people as they start
engaging in activities such as serving the food they have prepared, sharing their work
with significant others in the family, etc. Social skills get reinforced through
modelling and support from family members.
4. Decrease in negative and positive symptoms i.e. symptom control: Domestic chores
keep the PwMI engaged and divert them from the hallucinations and delusions which
they may be experiencing. Negative symptoms also gradually may decrease as work
habit is formed and interactions with people increase.
5. Increase in cognitive strength (Memory, judgment, critical thinking, decision making,
abstraction…): DS has a multi-sensory effect. All the sensory organs are stimulated
which contributes to an increased sense of awareness. Since chores such as operating
the washing machine, mixie, gas stove, cooking different dishes require cognitive
skills such as memory, judgment, critical thinking, decision making, abstraction, etc.
These skills also gradually can get strengthened.
6. Improved work performance & habit formation: Engaging in domestic chores
decreases the inclination to lie down in bed or sit by oneself (which can happen due to
illness or medication side effects). This involvement in work, getting out of bed on
time, etc. can become a habit and gradually encourage the PwMI towards vocational
7. Vocational Rehabilitation: Home based rehabilitation is an outcome of strengthening
DS. The PwMI has many avenues open to him/her such as preparing and selling
pickle, pappad, sambar/rasam/chutney powders, etc., operating a laundry (washing &
ironing clothes), manning a chaat shop, etc. With support from the family member,
the PwMI can start earning and become a financially contributing member of the
family which contributes to increased self-esteem, therapeutic FEC and helps him/her
recover with the illness.
8. Therapeutic family emotional climate (FEC): As the PwMI becomes functional the
FEC gradually becomes more positive and therapeutic since family members start
appreciating and recognizing his/her involvement in the family activities.
9. Appreciable quality of life (QOL): Once there is improvement in functioning globally
(occupational, social and symptom reduction) the quality of life also can appreciably
10. Therapeutic effect on illness: Delayed relapse, prolonged remission, symptom
reduction/control are add on benefits of strengthening DS.
What are the benefits of DS training for the caregiver?
1. Less frustration, less stigmatization, less work, more ME time, Better Quality of
Life(QOL): Since DS contributes to recovery, the caregiver faces less stigma and
hence frustration levels can come down. There is less perception of work over-load
also as the PwMI now becomes gradually less dependent on the caregiver. The
caregiver gets more time to take care of him/her self and hence there is better QOL.
2. Decreased caregiver burden and possible ensuing depression: As the PwMI becomes
more independent and other benefits of DS gradually are experienced, caregiver
3. Addresses ‘What after me….?’ question from caregivers. PwMI becomes more
independent in his/her ADL and may also become financially independent if he
engages in home based rehabilitation.
What are the benefits of DS for the mental health professionals?
1. Contribution of peer therapist (i.e. the recovering patient) who can become a pro-
active member of the PRS team
2. Possibilities of formation of self-help groups who can support the PwMI
3. Reduced burden on the mental health service provider system and the government too
Conclusion: Rehabilitation services should be need-based. Domestic skills training for the
PwMI is a felt need. Very few rehabilitation centres focus on strengthening domestic skills in
the PwMI. Domestic skills training is essential especially in a country like India where many
people are economically dis-advantaged and need to be self-dependent. Services of family
members, recovering patients and volunteers from society could be utilized in this training.
1. Sailaxmi Gandhi (2016). Role of Nurses in Psychiatric Rehabilitation Services. In C
Basavarajappa et al. (Ed.), Nuts and Bolts of Starting and Running Psychiatric
Rehabilitation Services (1st ed.). Bengaluru, India: NIMHANS Publication. ISBN No.
81-86464-00-X. pg 97 - 105
2. Sailaxmi Gandhi (Ed.). (2015). ‘ADL for Persons with Mental Illness: A Book for
Caregivers’. 1st Edition. Bengaluru, India: NIMHANS Publication. ISBN 818644100
3. Sailaxmi Gandhi (2014). Psychiatric Rehabilitation Services: A Nursing Orientation.
In Nirmala BP.(Ed.), Handbook of Psychiatric Rehabilitation Services (1st ed.).
Bengaluru, India: NIMHANS Publication. ISBN No. 81-86441-00-X. pg 160-171
4. Sailaxmi Gandhi (2010). Vocational Rehabilitation. In K.Lalitha et al.(Ed.),
Rehabilitative Nursing in Psychiatric Setup (1st ed.). Bengaluru, India: pg 33-37
Nurses Role in Psychiatric Rehabilitation Services
Dr. G. Radhakrishnan, Asst. Professor of Nursing, NIMHANS
Psychiatric rehabilitation services(PRS) are as important as any other treatment approaches
when it comes to the care of chronic and disabling mental illnesses. Persons with psychiatric
disorders are referred to PRS for various reasons including keeping oneself engaged, have a
productive daily schedule, promote/ develop good work habits, rehabilitation counselling,
assessing vocational potential/ aptitude, vocational training, training to improve memory &
concentration, training to improve socialization, exercise, leisure activity and recreation.
Nurses play a vital role in Psychiatric Rehabilitation Services. This article explores the
specific role of nurses working in this sector.
Clients chosen for the psychiatric rehabilitation services usually undergo complete
assessment in terms of the ability and interest/ willingness for a particular task and to find
the fitness of client for the rehabilitation.
The nurses provide valuable information to the physicians during the assessment based on
their close monitoring in the wards during recovery or from visits during their community/
Once the client is admitted/ allotted to the activities of the PRS, it’s the nurses who take care
of them during their stay in the PRS Unit. If the client is coming from a referral unit/
Inpatient department or from home as a day boarder, the nurse ensures the client has reached,
whether he had his meals and medication in the morning. Similarly, she also ensures the
client returns safely after the PRS activities.
This may well be handled through role call/ attendance register and close monitoring. Nurses
may take help of the nursing staff of the respective ward/ nursing assistants. If the client is a
day boarder, they may take the help of significant others who drop and pick them up.
During the rehabilitation process many clients may require assistance in their activities of
daily living, the nurses need to assists them in order to keep them groomed, presentable to
increase their self-esteem.
At times, clients may not be taking part in the activities assigned to him/ her, they need to be
encouraged, supported and guided in to their assigned rehabilitation task.
Many chronic mentally ill persons attending the psychiatric rehabilitation services do
continue to take medications as per the prescription. Hence it’s the duty of the nurses working
in this section to look after the care related to medication. Precaution, side effects, overdose
Family and Client education/ Consultation:
For a successful rehabilitation, involvement of the family members and their loved ones are
important. The nurses should educate family members on the client illness and its nature,
medications, handling the clients at home, what to and what not to expect from their client.
Explain the family about the client’s ability and inability.
Care during the rehabilitation/ working closely with the instructors:
The clients in the rehabilitation centres are assigned to various tasks and they work and get
trained under various instructors/ sections. Under these circumstances the nurses need to
closely work with the section instructors, interact with them regarding the client’s illness,
observe whether the client is able to adjust to the task and get the feedback from the
Nutrition and physical health:
Like in any other ward the clients in rehabilitation should be assessed for their nutritional
needs. The clients may or may not be able to express their needs in terms of food and
nutrition, assess their BMI and plan a menu accordingly and educate the family on the same.
Some clients may have existing chronic physical disorder such as Hypertension and diabetes,
keep these conditions in the mind while planning for nutritional needs. Excess BMI too is a
concern as it may lead to several physical problems
Advocacy is a part of our nursing role in PRS. The clients’/ family members need to be
oriented with the benefits/ schemes in which they get the government support. In a long term
care the family may face the financial burden that in turn reduce their interest in the client’s
rehabilitation. The nurses need to talk on behalf of the clients attending PRS where they do
not voice for their rights
Psychiatric Rehabilitation Services- brochure
NATIONAL INSTITITUTE OF MENTAL HEALTH & NEURO SCIENCES
DEPARTMENT OF NURSING
Dr. R. N Moorthy Workshop on Nurses Role in Psychiatric Rehabilitation Services
Program Schedule Date- 05/03/2016
Faculty/ Resource Person
Inauguration/ Photo Session
Mental Illness- Acute and Chronic Nature of Mental
Dr. Krishna Prasad
Mental Disability and its Assessment
Dr. Deepak J
Psychiatric Rehabilitation Services – meaning,
principles and its therapeutic implications and
importance of Psychiatric Rehabilitation Services
Dr. Sivakumar. T
PRS Team- Role and responsibilities of Psychiatric
Rehabilitation Services Team members/ Multi-
Dr. Poornima Bhola
Mobilizing resources for Psychiatric Rehabilitation
Services, Involving Volunteers/ NGOs
Dr. Aarthi J
Sections in PRS- NIMHANS, In- Patients and Day
borders at PRS. (Physical Orientation to the Psychiatric
Mrs. Glory. J (Nursing Tutor)
Infrastructure and facilities required for Psychiatric
Rehabilitation Services. Ideal Setup for Psychiatric
Rehabilitation Services in a general hospital - Physical
Dr. Hareesh A
Domestic skills Training and its therapeutic values
Dr. Sailaxmi Gandhi
Nurses Role on Psychiatric Rehabilitation Services
Dr. G Radhakrishnan
Discussion/ Q&A Session/ Clarification
Distribution of Certificate
NATIONAL INSTITITUTE OF MENTAL HEALTH & NEUROSCIENCES
DEPARTMENT OF NURSING
National Workshop on Nurses Role in Psychiatric Rehabilitation Services
(Funded by Dr. R. N Moorthy Foundation)
Date & Time- 05/03/2016 at 9.00am
Venue- Arts Theatre
Inauguration -Program Agenda
1. Prayer song- MSc Students
2. Welcome address- Dr. S.K.Chaturvedi, The Dean, Behavioural Sciences
3. Lighting the lamp- Dignitaries
4. Over view of the workshop - Dr. Jagadish Thirthahalli, Head- PRS
5. Prize and Distribution for the winners in the Art competition conducted at
PRS- From the Director
6. Certificate Distribution for the Training course conducted at PRS for the
persons with disability- From the Director & Registrar
7. Address by the Registrar
8. Address by the Director
9. Vote of thanks- Dr. Ramachandra, the HOD- Nursing
10. National anthem
Master of Ceremony- Dr. Radhakrishnan, workshop organizer
National Workshop on Nurses Role in Psychiatric Rehabilitation Services
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