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Psychosocial rehabilitation and severe mental disorders: a public health approach.

Ten years ago the World Health Organization consensus statement on psychosocial rehabilitation - the use of the term psychosocial, instead of psychiatric, must be noted - implied, as indicated by Wulf Rossler in his careful review, a shift from an illness model towards a social functioning model (1). This underlying premise leads to two broad intervention areas: the first is aimed at improving the individuals' competencies, the second is aimed at introducing environmental changes to improve individuals' quality of life. However, in the following years much more emphasis has been put on the development of individual-based approaches, leading to a narrow view of psychosocial rehabilitation as a set of more or less defined techniques targeted at chronic mental disorders and enlightened by a generic humanitarian concern for the fate of the mentally ill. 
 
Although the development and refinement of effective skill-building intervention models are welcome, we need to strike the balance by reframing the vision of psychosocial rehabilitation as a public health strategy and examining its implications in terms of practice, research and policy. 
 
 
To this respect, the following key issues can be briefly outlined: 
 
 
Psychosocial rehabilitation is not a technique. It is a strategy operating at the interface between the individual, its interpersonal network and the wider social context. 
 
 
The standpoint of psychosocial rehabilitation has to be humanistic, not humanitarian. The humanistic approach blends together an ethical and a scientific position. 
 
 
The target of psychosocial rehabilitation is functional disability, not chronicity. We have evidence that problems in social functioning can be observed at the first onset of many mental disorders, raising the need for early rehabilitation approaches. Even in acute conditions, such as the posttraumatic stress disorders occurring in the aftermath of disasters, the role of rehabilitation has to be recognized. 
 
 
The target of psychosocial rehabilitation are the psychosocial risk factors leading to the development and maintenance of social disability related to mental disorders. A growing body of methodologically sound investigations shows the significant role in major mental disorders of social/ environmental risk factors, such as migration (2), urban living (3), racial discrimination (4), childhood traumas (5). 
 
 
The overarching goal of psychosocial rehabilitation can be summarized under the heading of social inclusion. Therefore, attention has to be paid to the social/interpersonal outcome indicators, as distinct from clinical outcome (6). 
 
 
 
 
Within this frame of reference, consumers, clinicians, researchers and policy makers have to play their roles. The contributions of psychiatrists will depend on their capacity in developing and strengthening the skills recently indicated by Rosen in his description of the "community psychiatrist of the future" (7). I hope we will be able to meet this challenge.