[The psychosocial rehabilitation in addiction medicine]

OBJECTIVES

Addictive behaviors constitute complex behaviors that are usually related to social habits, such as substance use, gambling or gaming activities, or sexual or physical activity. They progressively overrun and stifle the routine habits of the concerned individuals, for example within their occupational or family spheres of life, as well as in their hobbies or in their main physiological functions, such as sleep or eating cycles. The rehabilitation approach of care integrates the objective of restoring the altered habits and functional rhythms, to optimize the clinical outcomes and improve quality of life of the concerned persons.

METHODS

Using a focused and narrative literature review, we aimed to explain what psychosocial rehabilitation consists in, and why this approach is particularly relevant for the addiction care, although to date it has remained insufficiently developed in the routine practice of many facilities.

RESULTS

The "rehab" approach, is first based on a structured and comprehensive assessment of the clinical and functional aspects of the patient, which secondarily allows to frame an individualized project of care that is closely built together with the patient. This project of care can integrate classical pharmacotherapeutic and psychotherapeutic tools, but it also emphasizes wider approaches for restoring some basic social and physiological functions of the concerned person, such as sleep, eating, social functioning, physical activity, or spiritual needs. Priorities among these different dimensions have to be defined by the concerned person.

CONCLUSIONS

The "rehab" approach is particularly relevant in addiction medicine. It represents a more global conception of care that conceives the recovery of social and physiological functioning as a core treatment objective for the concerned persons. The consequences for care organization are that many additional professionals should be integrated into the treatment schemes for addiction, including peer counselors, occupational therapists, physical activity coaches, or dieticians.

[Peer support programs in mental health in France: Status report and challenges]

OBJECTIVES

Recovery is a process through which people experiencing mental illness learn to live with their disorder and reach social insertion and citizenship. This positive approach focuses on a person's competencies and strengths rather than on the symptoms. Within this philosophy, peer support has been unevenly developing in mental health services worldwide with roots in the South-American social programs for homeless people and in the American recovery circles in the field of addiction. Therapeutic efficiency of peer support has been proven by several studies including a control group, as being at least as good as traditional services and even better in some specific areas such as reduction of need for emergency services and ability to reach "difficult" patients. The integration of former psychiatric services users in mental health services can take several forms, from the participation to scientific research studies to the direct involvement in a professional team at mental health facilities. In this context, our research aims to sum up the situation in France in comparison with other countries.

METHODS

We conducted a worldwide literature review in English and in French on peer support experiences and policies in mental health services, using medical and psychological databases (PsycInfo, PsycArticles, SantéPsy, Cairn, Medline, Wiley Interscience and PubPsych) on a recent period: 2005-2016. In total, 32 relevant scientific papers have been included in our research. In some cases, we have also used official reports, blogs, Internet sites, and mass media articles when they were relevant.

RESULTS

Our results show that this movement has been long to develop in France, with controversies having been raised since the beginning on the role that peers should play and confusion with existing social integration programs in the associative sector. Drawing inspiration from the Canadian model, a recent "peer mentor" initiative has been analyzed after 2 years of existence: many benefits for services users such as the optional aspect of this care process, a more authentic therapeutic relationship, a less normative frame, an active partnership, and a more optimistic philosophy aiming to make "small steps" towards improvement have been reported. Health professionals and peer mentors themselves have found benefits during the process. However, several limits such as difficulties to find a place with regards to the psychiatric team and difficulties to take advantage of the peer specificity, resulting in a significant attrition of the number of peer mentors, could be observed. A few other important initiatives focused on social insertion and using the help of professional peer support have been developed in recent years, but they seem to have encountered the same issues about positioning themselves both in terms of day-to-day integration in the professional environment and in the job title given by institutions which rarely corresponds to their experience and specificity. In addition, it remains difficult to obtain reliable information, as only a few papers have been published on this matter. Also, while some evaluation studies are currently being carried out, independent quantitative studies of the few running programs seem to lack in this field.

CONCLUSIONS

In our presentation, taking into account the difficulties that were raised in French programs and the lessons of practical experiences at work in other countries, we propose recommendations for larger and more effective implementations of peer support programs in France. As this new kind of care is emerging and seems promising in terms of benefits for not only the users but also the peer supporters and the teams of health professionals, we also insist on the need for a systematic scientific and objective evaluation of the programs.

[What support of young presenting a first psychotic episode, when schooling is being challenged?]

Psychiatric disorders (more specifically mood disorders and psychosis) represent the 1st cause of disability among young people. Unemployment rate between 75 to 95% for the person with schizophrenia. It is correlated to poor social integration and bad economic status, worse symptomatology loss of autonomy as well as global bad functioning. It is responsible of more than half of the overall cost of psychosis. The onset of most of psychiatric disorders occur between the age of 25 and 35 years old, a critical time in young adult life when they should build their professional as well as social future. Without appropriate care, young adult are unable to build satisfactory emotional relationships, continue their studies, live independently or fit into life. They are frequently dependent on their environment. They also have an increased suicide rate and frequent comorbid substance abuse. Despite this context, their care pathway is often marked by a delay or premature stop of care, drug treatments not always suitable and a lack of specific relay post-hospitalization regarding continuity of professional training or studies. All factors impacting future employability of adolescents. Furthermore they spend most of their time in school and school plays a key part in an individual's development including peer relationships, social interactions, academic attainment, cognitive progress, emotional control, behavioral expectations and physical and moral development. These areas are also reciprocally affected by mental illness. The initial phases of FEP are characterized by impaired academic performance, change in social behaviors and increasing absences from school, reflecting the prodrome of the illness that leads to disengagement from education. Functional decline often precedes onset of clinical symptoms and many adolescents and young adults are therefore isolated from school before their illness is recognized. School support staff may fail to recognize those who are functionally impaired because of evolving FEP although school is a key setting for promoting positive mental health, fostering resilience, detecting and responding to emerging mental ill health. So, people with psychotic illness have low levels of secondary school completion. School dropout has been defined as leaving education without obtaining a minimal credential, most often a higher secondary education diploma. In France, the school is compulsory up to the age of 16. Consequences are significant: among young people without a degree out of initial training for one to four years and present on the labour market, 47% are unemployed. School dropout depends on a number of factors, including grades, family and social environment and the relationship with the school, but also the emergence of psychiatric disorders. For first episode psychotic patients, age of onset, lack of family support, longer duration of psychosis, levels of premorbid global functioning and education, negative and cognitive symptoms, addictions, depressive comorbidities and stigma plays an important role in school dropout. However, young adults have historically received less treatment than expected considering prevalence of mental illness at that age. In the last few decades, early intervention programs for psychosis have been developed all around the world in order to promote rehabilitation and prevent long-term disabilities. Early intervention programs focus on the special needs of young people and their families and engage in some form of assertive community treatment, which attempts to treat patients in the community rather than using inpatient services. For early intervention in psychosis programs, the goal is to keep patients engaged with treatment, prevent them from further psychotic episodes and hospitalizations and promote rehabilitation. The additional services of an early intervention program include staff specialized in psychosis treatment, family/group/individual counseling sessions, assertive case management, and low-dose second generation anti-psychotics. In these programs, psychiatric rehabilitation practitioners already use individual counseling and supported education programs (SEd) to improve postsecondary educational outcomes. The goals of SEd are for individuals with serious mental illness to successfully be able to set and achieve an educational goal (e.g., training certificate or degree), to improve educational competencies (literacy, study skills, time management), to navigate the educational environment (e.g., applications, financial assistance), and to improve motivation toward completing educational goals. These approaches are often combined with efforts to support transitions to sustainable employment. Current evidence of these interventions are weak with limited information on specific difficulties experienced by young adults with FEP in educational tasks. Adaptive strategies are needed by young adults with FEP to succeed in educational settings but most studies do not explore it with rigorous methodology. However, common SEd components emerge: specialized and dedicated staffing, one-on-one and group skill-building activities, assistance with navigating the academic setting and coordinating different services, and linkages with mental health counseling. Continued specification, and testing of SEd core components are still needed. It is important that occupational therapy researchers and practitioners develop, and evaluate effective interventions to improve education outcomes for young adults with FEP. The objective of this work is to define school dropout, assess causes and consequences of FEP. How to help young people to maintain education? We will detail measures to support the academic re-insertion in France.

[Advocacy for the establishment of a comprehensive strategy to reduce the "burden" of schizophrenic disorders]

This article attempts to identify and put into perspective the different approaches that could globally prevent the suffering induced by schizophrenia, from the detection of early psychosis to the impact on individual and family functioning and emotional health. Schizophrenia causes, at the community level, a number of difficult consequences and associated costs, which likely could be reduced if specific strategies, already known and documented internationally, were applied. Two areas not explored in this article: the role of medication and the issue of suicide prevention. In the scope of screening and early treatment, genetic risk, as well as the predictive ability of the clinical criteria for individuals at "ultra-high risk" of developing schizophrenia justify an increased vigilance for the detection of symptoms in order for treatment to begin earlier and to be more effective. These risk factors should not be neglected as the benefits of early management impact the course of illness and functional outcome. At this stage of the emergence of the disorder, it is difficult to systematize a therapeutic protocol. Two options are open to the clinician: "wait and watch" given the lack of a conclusive diagnosis and a more pro-active intervention, focused on the therapeutic alliance and enhancing insight and awareness. The second approach seems more productive but requires transparency with the patient and family regarding the uncertainty of the clinical situation, and an attitude that favors sharing information, along the lines of early psych education. Once a pathological stage is reached, early and accurate clinical care is fundamental. They depend heavily on access to care, proximity and availability to clinics or out-reach teams, capable of a thorough diagnostic work-up. Yet conversely, the availability for early and accurate clinical care faces obstacles which are closely related to the pejorative view of psychiatry held by the general public, health care professionals, and public officials. This poor image of psychiatry is partly due to cases of clinical decompensation, dangerous in some instances, underscoring why it is be important to understand and anticipate the contributory factors to these outcomes in the first place so as to avoid them. In this sense, defending a complacent and conciliatory approach can be counter-productive. Following developments of recent decades in other chronic diseases (diabetes, cancer, AIDS, severe heart disease…), the implementation of systematic clinical programs, treatment protocols, psycho-education to reinforce adherence to therapeutic measures, their simplification, the support and appreciation of the role of caregivers, destigmatizing due to proximity of contact, and therefore an increase in the use of care. Similarly, the systematic search for side-effects of medication and pro-actively managing to minimize their occurrence strengthen compliance, a recognized factor of relapse prevention. Preventable comorbidities, addictions, and common physical illnesses are not systematically screened (neoplastic diseases, diabetes, hypertension, dental health, gynecology…) in this population and thus also represent significant potential for a better life expectancy. The tools of psychosocial rehabilitation, unfortunately, are too infrequently used in France. Their goal is to improve the functional outcome of patients, a determinant of social integration and to lessen the burden shouldered by family and other carers, and ultimately to reduce exacerbations of the illness due to situations of interpersonal stress. Work has also proven its worth as a protective factor, as well as strengthening a sense of self-efficiency, of self-esteem, of empowerment, of quality of life, helping attain recovery. It is clear that not all social and health care systems are primarily geared towards these objectives, although they have at their disposal, by the means described above, strong preventive measures for relapses. Beyond the issue of the implementation of clinical programs, the existing culture would benefit from being infused with a prioritization of resource deployment, with debates of these issues regarding parity for mental health services, advocated by users, and forging a place, for example, for the intervention of "peer supports", sociologists, social workers, interested beyond the disease, in community environment, employment opportunities, and housing. Overall, this work argues for updating our conceptions of clinical care, supporting the systematic implementation of modern models of care, and expanding the scope of our concerns regarding patients' lives.

[Cognitive remediation and work outcome in schizophrenia]

Recovery is partly defined by the patients' capacity to work, since doing well in a job favors hope and responsibilities' taking. Diminished job placement or tenure is linked with cognitive disorders, which impact directly and indirectly (through negative symptoms) functional outcomes. Attention, executive functions and working memory disorders can result in an alteration of the ability to manage the tasks required in the workplace. Executive function, working memory and social cognition disorders may also have an impact on behavior in relationships. Cognitive disorders do not automatically directly contribute to vocational outcome, yet their effects may be mediated by other variables such as symptoms, metacognition, social skills and intrinsic motivation. Then, since all these dimensions have to be taken into account, reducing the impact of cognitive troubles becomes a major challenge for the care of schizophrenia. Cognitive remediation is the more effective therapeutic tool to reduce cognitive dysfunctions. It rests in particular on the development of new strategies that allow taking concrete situations into account more efficiently. Cognitive remediation reduces the detrimental consequences of cognitive disorders and permits their compensation. It has emerged as an effective treatment, that improves not only cognitive abilities but also functioning, as it has been shown by numerous randomized controlled studies and several meta-analyses. The present article considers the effects on cognitive remediation on work function in schizophrenia. Several randomized controlled trials that compared supported employment alone versus supported employment associated with cognitive remediation showed significant improvement of employment rates in the latter condition. These results favor the use of cognitive remediation before job placement. The specific needs of the occupation that will be provided and the cognitive profile of the user should be taken into account.

[Practices and interventions related to the work integration of people with a severe mental illness: work outcomes and avenues of research]

Sustained work integration for people with a severe mental illness or handicap psychique in French (e.g., schizophrenia) is an important issue in our society today. Indeed, work is not only an essential factor in people's social integration but is also a stepping-stone toward recovery for this clientele. Well-defined programs and services related to work integration were developed and studied over the last three decades. Although the work integration of people with severe mental illness has been studied extensively in the Anglo-Saxon literature, the impact of these studies on the traditional beliefs and services in France remains uncertain. In terms of the scope of the studies so far, there has been an initial interest lasting over many years to uncover individual characteristics of people with severe mental illness which would best predict job tenure. Since, studies have been increasingly investigating various supports in order to facilitate the work integration process. These supports can be illustrated as direct supports or accommodations offered in the workplace, as needed, particularly when people with severe mental illness choose to disclose their mental disorder in the workplace. This awareness of the impact of the workplace environment on the work integration of people with a severe mental illness increases the need to find solutions and develop environmentally sensitive clinical strategies to overcome difficulties during the work integration. To illustrate this thematic, in this special issue, we have gathered together studies conducted in different countries but who share the focus on work integration of people with a severe mental illness. To reflect the advancement in this domain, this special issue is divided in three parts. The first part consists of the presentation of different types of vocational programs: supported employment programs, social firms, and hybrid models. Supported employment programs are very well documented in the specialised literature and are recognized as an evidence-based practice across the world to help people get competitive employment. Social firms is an another alternative model for facilitating the work integration of people with severe mental illness but has to date scarcely been studied empirically. Other hybrid vocational programs implemented in Québec (Canada) and France and inspired by supported employment programs and social firms' principles, are also described. The second part of this special issue is related to the presentation of two adjunct clinical interventions for helping people with a severe mental illness in their work integration, and more particularly for increasing job tenure: cognitive remediation and group cognitive behavioral therapy. Cognitive remediation was developed to reduce the impact of cognitive deficits, such as memory or attention, in people with a severe mental illness whereas group cognitive behavioral therapy was developed to change the dysfunctional beliefs and behaviours that might hinder job tenure in people receiving supported employment services. Finally, the third part of this special issue presents two papers on the influence of the workplace, of stakeholders from the organization (e.g., employers, supervisors) and of the work environment on the work integration of people with severe mental illness. The first paper discusses disclosure of the mental illness in the workplace and its positive and negative consequences such as receiving work accommodations and experiencing stigma, respectively. In the last paper, psychological processes during the hiring process are presented to better understand the elements related to discrimination and stigma during the work integration of people with severe mental illness.

[Challenge of social reintegration after a first-episode psychosis]

One of the main issues of early intervention in first-episode psychosis is to prevent social exclusion, or at least to seek to reduce it as soon as possible. The aim is not only symptom remission and relapse prevention, it is also to optimize the social and functional outcome of the illness. Social exclusion is not only one the disabling consequences of the illness, it is also, due to a negative circularity, an aggravating factor. Therefore, alongside the healthcare strategy aiming at the remission and relapse prevention, it will be useful to set up, at an early stage, a strategy aiming at maintaining or restoring social inclusion, and more generally to support the social recovery. We will specify the factors conditioning such prospects for recovery, and the variety of measures to support this strategy.