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Alex Raben: [00:00:10] So welcome to PsychEd, the Psychiatry podcast for medical learners by medical learners, and today we have an episode on psychiatric rehabilitation with Dr. Abraham Rudnick. And this is an interesting episode because usually we, behind the scenes, do a lot of preparation for our episodes and we know a lot already about our topic, and this time we don't really know what to expect. So that's a first for us. Before we get started, though, let's do our introductions. So I'm Alex Raben, I'll be hosting today, and I'm joined by my colleague Aarti Rana.
Aarti Rana: [00:00:49] I'm Aarti Rana. I'm a second-year psychiatry resident here at the University of Toronto.
Alex Raben: [00:00:54] Yes, and we're joined today, as I said already, by Dr. Rudnick. Dr. Rudnick, can you give us a bit of an introduction to you, please?
Dr. Rudnick: [00:01:01] Sure. No problem. And thanks for asking me to do this. So I'm a psychiatrist. I'm also a PhD trained philosopher, and I'm a certified psychiatric rehab practitioner. I'm just now moving into a new position. So moving from Ontario to Nova Scotia to be the Clinical Director of the Operational Stress Injury Clinic of Nova Scotia and a Professor of Psychiatry at Dalhousie University with a cross-appointment to occupational therapy at Dalhousie, which is very relevant to psychiatric/psychosocial rehabilitation, because obviously occupational therapy has a lot to contribute as well as other mental health services.
Alex Raben: [00:01:44] Great. Thank you for that. And where are you coming from?
Dr. Rudnick: [00:01:47] So maybe just a tiny bit of preliminary background even before my most recent position. So I was trained in psychiatry and medicine first, then military medicine, then psychiatry in Israel, which goes back to my roots a bit in military medicine. Then I did a fellowship at University of Toronto with a double focus, one in philosophy of psychiatry and one in psychiatric rehabilitation at what was then called Whitby Mental Health Centre, which is now Ontario Shores, and during that I also certified through an American national organisation in psychiatric rehabilitation. And most recently I've been the executive Vice President of Research and Development and Chief of Psychiatry at the Thunder Bay Regional Health Sciences Centre in Ontario, as well as a Professor of Psychiatry at the Northern Ontario School of Medicine.
Alex Raben: [00:02:45] Great. Thank you for that. So maybe we can start off by unpacking this term, psychiatric rehabilitation, because it's not something that, at least in our curriculum here at U of T we use very often or I've honestly never really heard those two words really put together. And when I think about rehabilitation, I think more physical rehabilitation, like physiotherapy after an injury or something like this. Can you help our audience who may also be like me and not very familiar with this terminology, understand what it's all about?
Dr. Rudnick: [00:03:18] Absolutely. And I think it's symptomatic in a sense that you haven't heard about psychiatric or psychosocial rehabilitation, those are synonyms, because we don't expose our learners both in psychiatry as well as in social work or even occupational therapy, psychology and nursing enough to this. Psychosocial or psychiatric rehabilitation is one of the four main types of mental health intervention, one being pharmacology, another being psychotherapies in plural, a third being all the types of neurostimulation like ECT, TMS, DBS and so on and the fourth, last but not least, is psychiatric rehabilitation. So it's a whole world of evidence-based practices that focus on facilitating recovery of people with serious or other complex mental illness. Primarily historically, it was focused on people with schizophrenia, but that goes much beyond people with schizophrenia these days. The idea of recovery is a key point. And as you may know, the Mental Health Commission of Canada has highlighted recovery as the ultimate goal of all mental health services for all populations served by mental health services. And so maybe, just very briefly, I'll unpack what does recovery mean because if we understand the goal, we can understand the means to achieve the goal. So there are at least two types of meanings for recovery. One is the more traditional meaning, which is a set of outcomes that's called clinical recovery by people like Mike Slade, and that's about symptom reduction or alleviation, that's about more independent functioning, those types of outcomes. But the second sense of recovery or what's called personal recovery are the processes of recovery, which is about seeking, finding and keeping a meaningful personal life. And immediately you can imagine that that goes much beyond pharmacology or even psychotherapy. It's about the whole person's life. And that's where psychiatric rehab comes into play, because it focuses very much on helping people live the best life they can in their environments of choice. And if we have time, I'll explain a bit more, what does that technical term "environments of choice" mean.
Aarti Rana: [00:05:55] When you speak about recovery, usually recovery is referring to some kind of injury or event. And so in a physical rehab model, for example, someone might have a knee injury, they might be a military survivor of military combat. I imagine looking at psychiatric illnesses in terms of the concept of recovery would change how we think of the illness itself in some way. So how might someone thinking about recovery think about schizophrenia differently, for example?
Dr. Rudnick: [00:06:30] So they it's a great question. The idea of recovery is that, as Bill Anthony from Boston University said, we all recover from something in life, be it a divorce, be it unemployment, be it a loss in the family, be it an unaccomplished dream, and people with mental illness, in addition to many of those challenges, also have a mental illness to to address and cope with. So in a sense, recovery is not specific to mental health issues, but in the mental health sector, in the last 2 to 3 decades, particularly from the States and then after that in Canada, Australia, New Zealand, UK and other countries, the idea is developed into a whole social movement saying that recovery's goal is really not just about the adversity we face, it's about society accepting anyone with any kind of adversity and challenge fully. And so in the States it's been fairly political movement that has aligned well with psychiatric rehabilitation but is separate from psychiatric rehabilitation. Although there are a lot of people who straddle both camps. The main leaders of the recovery movement obviously are people who are recovering. So people who have had or still have mental health challenges. Some of the most famous ones internationally would be people like Patricia Deegan, who is a PhD psychologist who has published research on coping with voices for example, as well as on shared decision making in regards to mental health care. Still, according to her public acknowledgement, still receives treatment, still experiences symptoms, but still has a full life in spite of that, and sometimes even partly because of that, because it has brought new meaning and new purpose into her life. So when we say recovery, we don't mean cure. We don't even necessarily mean symptom remission, what we mean is people living a full life according to their hopes and to their abilities.
Alex Raben: [00:08:46] I have some questions about how we achieve the recovery, but before we get there, I'm having a little bit of trouble with some of the terminology because, right now I'm working in an ACT team, so we are very much recovery-focused and yet I've never really heard this rehabilitation terminology. And you're suggesting there might be actually two camps or a recovery and a rehabilitation camp. Are they different? Is there a lot of overlap? Are they the same? Is it just different preference and terminology?
Dr. Rudnick: [00:09:12] There's a lot of overlap. The terminology is fairly similar. I would say each country and even each province in Canada would have a slightly different take on that because it's quite contextualised. But by and large, the recovery movement is composed of people with mental health challenges and people who support them. And the psychiatric rehabilitation sector is not an ideological movement anymore, it was decades ago, it's now really an evidence-based set of practices that continues to change based on research generated and helps facilitate recovery based on the visioning of the recovery movement.
Alex Raben: [00:09:57] So it's like a yin and yang, almost? Okay.
Aarti Rana: [00:10:00] Could you describe where psychiatrists who are practising psychiatric rehab, where are they working? Are they working in the same hospitals that we would be doing our residency rotations in? Are there specific centres that they work in? Are they working privately and how does their work look different than the work of other psychiatrists who are working with similar patient populations?
Dr. Rudnick: [00:10:22] So it's a whole mix in different areas of the mental health system. But I would say that there are not many of us who actually do full-fledged psychiatric rehab, partly because there are very few psychiatrists who are certified in psychiatric rehab in Canada, even in the States, not many, but some are, partly because there are more traditional understandings of what recovery and recovery and psychiatric rehab mean by many of our colleagues. And so one of the things I've published about in my research is the notion of coercion in psychiatric rehabilitation. And we all know that legally coercion is sometimes allowed and even required in treatment, in enforcing medications when people are incapable and a risk to themselves or others. But some psychiatrists still think that that is also possible for psychiatric rehab and if you understand the basic definitions of what psychiatric rehab is, which is helping people achieve their life goals, then coercion is by definition not possible because no one can impose life goals on someone else. If they do, that's not a life goal anymore. So there's a logic to this that is a very strong logic and of course has ethical implications. And therefore, other than in very special circumstances like forensic systems where psych rehab is constrained, it is constrained, but parts of it could be allowed in all other aspects of mental health care. It's all about personal choice of the service users. And I think we need a lot more dialogue with psychiatrists and others about how does that look like when there's no coercion, not even an attempt to influence in a subtle, coercive way people's goals in life.
Aarti Rana: [00:12:20] So I'd like to try to summarise what you're saying. Someone who's practising psychiatric rehab in this way would be working with patients to try to identify their own goals in life and then adjusting what they do as a psychiatrist to help the patient further those particular goals. So the system that we work in would be secondary to what the patient's trying to do with their own life.
Dr. Rudnick: [00:12:48] Absolutely. And we would be, the whole mental health sector including psychiatric rehab, would be only one fairly small piece in the whole puzzle of a person's life, including the supported parts. And so in that sense, psychiatry can be flipped on its head and looked at as a support, not the lead of the person's life, but just the support that sometimes is needed and sometimes is not whether the person is or is not symptomatic. And therefore the person with the mental health challenge is the driver of their recovery-oriented care.
Alex Raben: [00:13:27] I was going to ask who defines recovery? And it sounds like from what we're saying, it's the person who's being treated or who has a mental illness. What about like, I'm thinking about my own clinical work, what about scenarios where the person has schizophrenia, and they have negative symptoms and they don't have much motivation to really come up with goals? Is, what would someone who's practicing from this frame of mind do in that scenario? Would they start to work with them to help them think of goals, or would they say no, actually their goal is just to be by themselves and be asocial, and that's how it's going to be.
Dr. Rudnick: [00:14:04] That's a great question and a segue into the process of psychiatric rehab because there's a structured process to go through. This is not just an art. And so Boston University is an example, their psychiatric rehab centre has published for decades now that approach of, how do you help people who are not clear on their life goals get to the point where there's clarity and then psychiatric rehab can start. Because if the goals aren't clear, then we can't really proceed. PSR, psychiatric rehab, is focused on people's life goals. So there is a process, a preliminary process called readiness assessment and development. So psychiatric rehabilitation readiness assessment and development, it's not exclusive of people. It doesn't say people are not ready to, just helps better understand the clients as well as the providers at what level of readiness the person is. It's structured into a few components. The first and most important probably is does the person have a felt need for change in their life, in any aspect of their life, in what we call environments of choice, be they residential, vocational, educational, social, sexual, health care, environment, spiritual and so on. If they don't, then there's a dialogue. Why not? If it looks from outside like maybe their life is not that great, but it's their choice to change or not.
Dr. Rudnick: [00:15:32] If they do have a felt need for change then there's another component of readiness, which is are they committed to invest effort, time, sometimes even money into change? We know from behavioural change in general, in the general public, that a lot of people feel a need for change. But when it comes down to committing to that, for example, weight reduction, it's not that easy. And so if a person isn't committed enough, maybe it won't work. And there are a few other components of readiness, such as awareness of personal values and preferences, awareness of environmental possibilities and what's not possible, and eventually also the ability to connect with someone to work on this together. If the person isn't ready enough to put in place a goal for rehab, then there's a structure, that a process that looks very similar to motivational interviewing and often actually uses motivational interviewing to help them explore whether they do want to change their readiness. And so that's one of the interfaces between psych rehab and psychotherapy, for example. There are many other interfaces, so using skills from motivational interviewing can very much facilitate that readiness assessment and development process.
Alex Raben: [00:16:48] And then along the same example, does at that very early step, does it ever is there ever a point where you say it's the person's mental illness that is preventing them from forming goals and we need to treat the mental illness, perhaps even coercively, before we can get to those goals.
Dr. Rudnick: [00:17:08] It can happen. From my experience, it's not often that that happens because even if a person is actively psychotic and let's say their goal seems to be delusional, there are ways to break down a goal. And this is coming from human services, not from the health sector. How do you break down, help people break down their ultimate goals into steps to achieve that? And so often during that process, the person realises that, as an example, they may have initially wanted to be an astronaut, but because it's very unrealistic plus they've discovered that their interest is actually in astronomy and not really in being out there in space, that they may actually shift or focus on those interim steps, interim goals and be more than happy with that. So typically, that would be the readiness process where you're exploring why and what in fine detail. As you can imagine, this can take many months to just get to a clear goal for rehab. So it's very time consuming, but that's okay. We know from physical rehab, which is a model for psychiatric rehab, that things sometimes can go slow, but so long as it's clear where they're going towards, it's fine.
Aarti Rana: [00:18:30] And let's say someone is ready. So they you identify that they are ready, they're committed, and they have a clear goal. What happens next?
Dr. Rudnick: [00:18:39] So now you start with the actual bread and butter of PSR, psychosocial and psychiatric rehab, which is about identifying what are the skills needed for that particular environment of choice. I'll define what that means in a moment and what are the supports. So the two practical pillars of work practice in PSR are skills and support. And as you can imagine, there are many types of skills: cognitive, emotional, practical, social and many other skills. And similarly, there are many types of supports: social, physical supports, time supports and other supports. And so the planning with the client is to identify, for their environment of choice, what skills they have, what skills they don't have but are needed as well as what supports they have and what they don't and what supports are needed. An environment of choice literally means what setting and what role in that setting the person wants. That's a rehab goal, the environment of choice. An example would be a person wants to be a tenant in an apartment. That's a role in a setting, that's an environment of choice, putting the role and setting together. And that's the goal. That's a very specific practical goal. Now, if they wanted to be a resident in a group home, it's also a residential environment, but it's very different. The role is not a tenant and the setting is not an independent apartment. So expectations for skills and supports are very different. They would have to have many less skills in a group home and many more supports. And most people, when you ask them, prefer it the other way around to have more skills and less support in order to be as independent as they can. And we do have in Canada still a system of many group homes which is called sheltered residential rehabilitation. It's not evidence-based and some people are there for life because they've been there for decades. But most people, particularly the younger population, would prefer to go to the supported housing sector, which is more skills and less support, but there still are supports as needed. And so that's the process you identify together. What are the skills and what are the supports needed for both success but also for satisfaction. And that's part of the complexity of rehab, because we all know from our life and that's the whole exercise of rehab is learning from ourselves, is that sometimes success conflicts with satisfaction. We hope to achieve both in an environment of choice, but that doesn't always happen. So when we're planning psychiatric rehab, we need to flesh out those issues. Could there be a conflict between success and satisfaction for the person. They may not have enough life experience to actually know that in advance, and that's part of our role, to help them think it through and make some tough choices sometimes.
Alex Raben: [00:21:47] So it sounds like from what you're saying, it's, psychiatric rehab is more of a framework almost where you then can plug in like psychotherapies, for instance, or cognitive psychotherapies, emotional psychotherapies to help build skills and then social supports to help fill supportive needs, rather than it being a single intervention in itself. Is that so?
Dr. Rudnick: [00:22:12] It's both, you're right, but it's both. It's both that framework where you can input interventions from other practices like psychotherapies, for example, but it also has its own set of skills-building interventions and support-building interventions. I should also add it's not just about building those skills and support, it's also maintaining the effective adaptive skills and supports because skills and supports, even if they're very effective, can easily erode. So if someone is in hospital for a few months, their basic daily activity skills may erode. And we need to be very mindful that long stays in sheltered facilities like hospitals may actually cause some harm. And therefore, if they're absolutely needed for safety, for example, then we need to do active work in those facilities, in hospitals and other facilities to maintain the skills the person is brought into the facility. And the same would go for supports, if someone is admitted to hospital and then they lose their apartment or are evicted and a new apartment is found, we need to make sure that the right supports are in place based on their recovery goals. And so a typical example would be someone is in hospital, they're now finding a new apartment, but there's no laundry facility in the building. So they need to do laundry, if their apartment is located in an area where there is no laundromat anywhere nearby, they may not be able to do laundry. That's a recipe for disaster. And it's very simple, very practical but we have to think of those aspects of life that are critical for people to live a good life.
Aarti Rana: [00:23:59] In a sense, what you're describing is a deep study of an individual, one at a time in a kind of n-of-one. So you have a whole system that one by one looks at the n-of-one and says, okay, what are the factors that are limiting the goals that this individual has identified for themselves?
Dr. Rudnick: [00:24:16] Absolutely.
Alex Raben: [00:24:17] So very personalised medicine already at our fingertips.
Dr. Rudnick: [00:24:21] Very. And very it could be very low tech because this is really about the interpersonal connectivity between the service provider and the service user. It could be expanded to more people, but the core of the intervention is you and the client. It could be the rehab practitioner and the client if it's not the psychiatrist leading the rehab part, but it could be a psychiatrist, which I found personally to be fascinating work because you actually are invited by the service user to every aspect of their life that they want to consider changing.
Aarti Rana: [00:24:56] You know, I happen to be currently in a psychotherapy seminar group and we're reading some of early Freud's early papers and he talks about listening to patients and actually listening and seeing what's there with a completely open eye because there was no psychiatry, right? There was no sense of what you're supposed to do. And what you're describing is a little bit of that as well. I wonder if you can speak from your background in philosophy to what you're doing in this model that wouldn't be present in other models.
Dr. Rudnick: [00:25:29] Yeah, absolutely. I think the first pioneers of psychiatry like Freud and even before him, Kraepelin and so on, were looking at the whole person. They didn't have the intervention means, even Freud initially, to actually make much of a difference in the person's life but they could actually look at the person's life and they did. So from a philosophical perspective, we're talking here about a holistic approach, not H-O, W-H-O- holistic, a whole person, but also a whole system approach. And there's a similarity to physical rehab, again, which was one of the sources of inspiration for psych rehab, which were we're looking not just at the person, we're looking at the fit between the person and their environment of choice. So if you look at the person with physical disability and how rehab work proceeds with them, it's about finding out what their goals are and then finding the fit, based on those goals, between the person and their environment. And if the environment needs to change, such as ramps for people in wheelchairs, elevators for them and so on, so be it, the environment has to change and it's legislated. It goes the same for people with psychiatric disabilities. That's the focus of psychiatric rehab. It's just sometimes a bit more difficult, challenging to figure out what are those technically termed "accommodations" in the environment that would optimally support the person.
Dr. Rudnick: [00:27:00] But the research is pretty clear. In general, there are many types of accommodations, but two that stand out are social supports in environments of choice and time flexibility. So in the work environment, for example, if someone has difficulty getting up on time because they're heavily medicated or because they have some negative symptoms, an employer who is flexible and accommodating would allow them to come late to work but then finish work late. So they're still working the full workday, but they're just shifting it. And so part of the work of rehab is to not just work with the service users, is to work with their environments. Very well known evidence-based model is called supported employment, specifically individual placement and support, IPS, highly replicated in randomised controlled trials and systematic reviews. And one of the jobs of the rehab practitioner there is to work with employers in general in their region, not even specifically in regards to a particular client, but to help them destigmatize, better understand and learn what supportive accommodations are so that the next client coming their way would be better accommodated.
Alex Raben: [00:28:15] You touched a little bit on the the literature there and the research, and earlier you said that it's not just about plugging things in,there is an actual sort of codified treatment here. So in my mind, I'm wondering like, is this sort of like CBT in the sense that people have written all this down? There's manuals, people practice in a certain way and then there's research on that. And if so, what does that research look like? What are the outcomes like?
Dr. Rudnick: [00:28:44] Yeah, absolutely, much of PSR now is manualized. An example would be IPS, supported employment, including fidelity measures similar to psychotherapies, where you can evaluate if a service is working enough to the model, close enough to the model, and they can be rated on that. And the research shows the lower the fidelity, the less effective the service is compared to what's been published in randomised controlled studies. So IPS would be a great example for that. There are practices that are not yet fully evidence-based in psychosocial rehab. For example, in the vocational rehab environment, social enterprise would be an example of a promising practice that has some research to support it, but it's not yet as evidence-based as IPS, as supported employment. But it's promising enough that people are actually doing more research, including randomised control trials on that. One of the challenges in that in the methodology of the research is that doing RCTs on each and every psychosocial intervention is sometimes challenging. And even psychotherapists would argue that for some psychotherapies, because randomisation of course removes choice to some extent and there are some challenges, you can't blind these interventions, the psychosocial interventions. So, you know, compared to biological interventions, they're considered a bit weaker. But there are statistical and other ways to strengthen the studies, including using quasi experimental research, which is not RCTs but if it's done with large enough samples, it can be very, very effective, very helpful, very informative. And so I think a lot of people are recognising that for some interventions, just sticking with RCTs may not be enough, we may need RCTs, but we also may need more creative, rigorous methodological designs in order to demonstrate whether an intervention is effective or not. And I and many other rehab practitioners don't use the term treatment because that's actually very specific to the biomedical approach. We use the very generic term intervention, treatment is one type of intervention, rehab is another type of intervention.
Aarti Rana: [00:31:07] So if you're a medical student or a resident in Canada and you wanted to have an opportunity to work and do an elective in this model, where would you go?
Dr. Rudnick: [00:31:16] So you would probably want to look up psychiatrist who are CPRPs or CPRRPs That's CPRPs is an American designation, psychiatric rehab practitioner. CPRRP is a Canadian designation, the Certified Psychosocial Rehabilitation Recovery Practitioner. They're on the websites. Very few of us psychiatrists with that, but we're available. I know some in London where I worked in the past, now in Nova Scotia, I'm there. There are a few others but if it doesn't have to be with a psychiatrist, there are a few occupational therapists, social workers who can supervise that. I would also encourage looking at getting that designation with enough training eventually and also there are courses in psychosocial and psychiatric rehab. So in Canada, the two at least two colleges who provide that online training. One is Mohawk College in Hamilton, another is Douglas College in in British Columbia. There may be others and it's those two are all online. So it's an opportunity to at least get the basics of the training of PSR with many other practitioners, including service users. So patients take those courses too. No one is excluded so long as they can play, it's a fairly nominal, pay, it's a fairly nominal fee and based on that you gradually get a very diverse workforce.
Alex Raben: [00:32:41] That's great. That's very helpful for our listeners who are who are finding this interesting and want to pursue it further. I'm wondering what does recovery look like? We've talked about that there's some literature, it does show that certain outcomes are improved in certain areas. But as Arthur, you were saying, this is very much an n-of-one process, kind of at the end of the day. Can you share with us what it actually looks like when you see recovery or when you're involved in that?
Dr. Rudnick: [00:33:10] Absolutely. So first of all, it's ongoing because life changes and so goals may change once in a while. But if a person has put in place goals of, let's say, working a full-time work with this certain amount of wages, that would be vocational recovery for them and it would have to also be a meaningful job. So if they're suffering from the job but earning well, then we have that clash between success and satisfaction. That's not ideal. Sometimes it's necessary, not just for people with mental health challenges, but it's better to try to plan or at least tweak it after that towards both success and satisfaction. And people just tell you, we can use all sorts of sophisticated psychometric tools, psychometrically validated tools and measures for that, but in rehab, actually, the bottom line is pretty simple. Has your goal been achieved? We can just say fully, partly or not at all, that's good enough to know do we need to continue to do rehab work in this particular area of the person's goal.
Alex Raben: [00:34:14] One area of discomfort for me around this topic is something you mentioned early on where you said that to be coercive, to use coercive means is to really not be in this model whatsoever. But thinking about my own clinical experiences, there's many times where safety is at play and where medicolegally we're responsible to be coercive. How does that fit into what we're talking about here?
Dr. Rudnick: [00:34:46] It fits well because psychosocial rehab is not a panacea. It can't do everything. There are times and situations where it's where our hands are bound, right. Public safety trumps and that has to be the case. Think about physical rehab. It's not like a physiotherapist can always do their work. If the patient is deteriorating, develops a fever, physio has to step back for a short while at least, and let other practitioners do what they can to help the person. So as everyone in rehab recognises, although the framework is a recovery-oriented framework, there are many other ways of achieving both safety as well as success and satisfaction. There are many service users out there who have never used psychosocial rehab and never will use and don't have a need for that because they have found their own way. Or maybe meds are enough for them and their own coping and own natural supports and that's fine. So really it's just part of the puzzle doing psychosocial rehab. But if we do it, there's no coercion, there should not be coercion involved because then we're not doing psychosocial rehab.
Alex Raben: [00:36:02] That helps me conceptually wrap my head around that, so thank you. I'm wondering if we can end off with just kind of any, I'm wondering if we can end off with what you would hope that a medical student or an early resident would take away from this, someone who's maybe not considering pursuing this as a career, but is going to be maybe a general practitioner or a general psychiatrist, what would you hope they take away from this podcast?
Dr. Rudnick: [00:36:33] So I'll use an adult education framework where we look at attitudes, knowledge, skills and awareness. So the very first is awareness, that people are aware that there is such a set of practices that are evidence-based and informed that can help people with serious and other complex mental health challenges. So I'd like people to be more aware, and I think medical students and junior residents should be aware that there is this set of practices that can help some of their clients. And then gaining more information, more knowledge, I think is also important so that at the very least, practitioners, even if we're talking about primary care providers who may not really be in the realm of providing psychosocial rehab services, at least know who to refer to, they're not just aware that there's such a set of practices, they know what's it about and who to refer to if they think there's a need, because these referrals don't have to go only through a psychiatrist. They could go through a primary care provider, through a social services worker, whoever is the right person, because there has to be a very seamless way for clients to access these services and at the somewhat more advanced level, people who want to be general psychiatrists, I think should have some basic skills in not necessarily providing psychosocial rehab, but at the very least facilitating and not obstructing it. The coercion challenge is one of those issues that people need to know what to do and that this is very different from treatment in the cases of people who are incapable, right, to decide on their own treatment. And last but not least, come the attitudes. And so positive attitudes, particularly always keeping in mind that there's hope and messaging that to clients is crucial. Without hope, there is no recovery. And so if there's no recovery, no goal set for that, there's no place for psychosocial rehab. And so I think those positive attitudes, not pollyannish, but real reality-based, positive attitudes that anyone everyone can grow and learn and change based on their hopes and dreams, I think is crucial. It's not just crucial for psychosocial rehab. It's crucial for life, for people in general, but for people with serious mental illness or other complex mental illnesses who often have been traumatised in addition to having their mental health challenges. And we know the rate of trauma for people with serious mental illness such as schizophrenia is so high, both pre morbid and after they develop their illness, without that hope messaged consistently it'd be very difficult to do any work, including medication, including psychotherapy work. And so I think psychosocial rehab and more generally the recovery approach can bring that hope and it's realistic because pretty much everyone can learn, grow and develop towards their own goals if they are their own goals.
Alex Raben: [00:39:42] So hopefully today we've built that awareness. People can then go from here and learn more about this on their own to gain that knowledge and then going forward, work on those attitudes with hope being one of the most important ones.
Dr. Rudnick: [00:39:55] Absolutely.
Alex Raben: [00:39:57] Just as a last note, do you have any resources or one particular resource you would recommend people go to as a way of finding out more about this topic?
Dr. Rudnick: [00:40:06] Yes. So there are lots of textbooks, including some of mine, and many journals. So the one journal I'll highlight, because I think it has a nice diversity of types of articles, both research and opinions and educational literature about PSR is the Psychiatric Rehabilitation journal published by the American Psychological Association. It's it comes out, if I remember, quarterly, it's quite helpful. And for textbooks I would probably still highlight the William Anthony et al. textbook. It's unfortunately now from 2002, that's the second edition. But it's, from my experience, one of the best for theory of psychosocial rehab and clinical practices. Now, if people want to look at the evidence, not just through journals, but through a textbook, then Patrick Corrigan's 2006 Psychiatric Rehabilitation textbook is a wonderful resource to see what's evidence-based in psychosocial rehab.
Alex Raben: [00:41:12] Great. So guys, we'll look into those resources and we'll post them in the show notes so that you have access to them. But I want to say thanks Dr. Rudnick so, so much for coming out today. You were originally up in Thunder Bay before and you had wanted to be involved and now you're down in Toronto for the CPA and so we thought we would snag you while you're here and it worked out really nicely. But thank you so much for that talk. I feel like I've learned a lot. Aarti, I don't know about you.
Aarti Rana: [00:41:40] Definitely. I feel like there's a whole new part of our ecosystem that I wasn't aware of before. And for me, I know a lot of the principles that drew me to psychiatry do rest in the psychosocial part of psychiatry. And so to know that there are further resources I can explore, people I can talk to, to build my training in that area is hopeful, as you said.
Alex Raben: [00:42:04] So and we hope that you guys, the listeners, have also learned a lot and we will see you next time. Thanks for listening.
Dr. Rudnick: [00:42:12] Thanks so much.
Jordan Bawks: [00:42:14] PsychEd is a resident led initiative based out of the University of Toronto. We are affiliated with the Department of Psychiatry at U of T as well as the Canadian Psychiatric Association. The content in our episodes is a representation of our own views and those of our guests. Our special thanks to our guest in this episode, Dr. Abraham Rudnick. The episode was produced and hosted by Aarti Rana and Alex Rubin. Post-production editing by Jordan Bawks. Our theme song is Working Solutions by Olive Musique. You can contact us at info@psychedpodcast.com or visit our website at Psycedpodcast.org. Thank you for listening. Stay tuned for more great content around the corner as we try and meet our goal of a monthly episode for all of 2019. Catch you next time.