Psychiatric rehabilitation in the era of globalization.
Authors: Michael G Madianos
Journal: World Psychiatry (2006)

Rossler's paper focuses first on interventions centered on the disabled individuals, aiming to enhance or develop their emotional and social skills, and then on the socio-ecological strategies supporting the rehabilitative process. Ten years ago the consensus statement jointly produced by the World Health Organization and the World Association for Psychosocial Rehabilitation also defined psychosocial rehabilitation as a strategy that facilitates the opportunity for individuals, impaired or disabled by a mental disorder, to reach their optimal level of functioning in the community, by both improving their competencies and introducing environmental changes (1). The psychiatric rehabilitation process focuses primarily on the patient's existing capabilities based on the  part of ego, but the restoration of these abilities is not mechanical and linear. Patients' civil rights and aspirations are always taken into account, but their needs of adequate education, work, housing and community acceptance are often confronted by legal, socio-cultural and economic constraints. Psychiatric rehabilitation interventions and techniques such as case management, social skills training, assertive community treatment and others have been proven to be effective, but their strengths are weakened or even  when the socio-cultural and economic environments are negative or even hostile to the recipients of the psychiatric rehabilitation programs (2,3).

Work is a basic rehabilitation goal and obtaining a job (full or part time) is always a desirable ambition. The question is how to get a job when unemployment rates are high. In most Western states, economic recession is a chronic phenomenon. This could cause difficulties even to supported employment programs. Moreover, the economic recession is always linked with psychosocial programs budget cuts.

Globalization of economy has brought serious economic changes (market economy), increasing unemployment rates (investments are moving to cheap labour countries), privatization of social institutions, high social mobility, transformations in the family structure, and marginalization of socially disadvantaged groups (e.g., unskilled workers, minority groups and disabled persons).

The growing economic insecurity causes a considerable burden especially to families with a member suffering from serious mental illness. These families are often facing profound economic hardship (4,5). Poverty has a significant negative impact on psychological wellbeing, self-esteem, health (physical and mental) and the quality of life in general (6). Particularly low levels of quality of life in its various domains (social relations, leisure activities, nutrition, housing) are experienced by individuals suffering from serious mental illness and their family members (7).

Moreover, the ongoing processes of deinstitutionalization of long-stay inpatients are involving the family and the community. When the family and the local community are unprepared or unable to accept the deinstitutionalized patients, those patients are likely to become homeless, or are trans-institutionalized. In these cases, psychiatric rehabilitation sounds ironic.

Apparently the era of globalization is having negative implications for the provision of effective psychiatric rehabilitation programs. The question is whether the impact of globalization can be eliminated or even neutralized for the benefit of the patient and the family. The answer is positive. There are solutions like the empowerment of the international movement of families and users of psychiatric services, with parallel efforts for self-actualization and self-determination of any suffering person. At the community level, the atmosphere could be changed by the systematic implementation of various mental health interventions directed at the modification of the local community's beliefs and attitudes towards the interactions of the mentally ill (8). The encouragement of volunteerism in the field of mental health and the exploitation of any available community resource for food, housing and work could somehow replace the absence of the social welfare state.

Psychiatric rehabilitation is a multidimensional and dynamic process, involving three parties: the patient/family, the state and the community. The process is taking place in a specific socio- economic environment, not in a vacuum. Every professional in this field has to be optimistic as well skeptical or critical to the role of the environment as a major factor in the implementation of effective psychiatric rehabilitation.