Past, Present and Future
Reprinted from "Recovery" issue of Visions Journal, 2013, 9 (1), pp. 10-11
People with serious mental illness, such as schizophrenia, are often psychiatrically disabled.1 To facilitate their clinical and personal recovery,2 psychiatric rehabilitation has been developed, studied and spread widely.
Psychiatric rehabilitation is a set of value-based and evidence-informed practices used by various professions, such as occupational therapy and nursing, that helps people with mental illness enhance and maintain adaptive skills and supports, such as work skills and social supports. The goal is to help them be satisfied and successful—that is, have personally meaningful and socially valued roles, in their environments of choice—residential, educational, vocational, social and other.3 More traditional psychiatric approaches tend to focus primarily on alleviating symptoms. Psychiatric rehabilitation, however, focuses initially on service users’ goals, rather than on their problems. This is particularly helpful for personal recovery, while also being ethically sound, as putting the person’s goals first as a rule (with exceptions, such as to protect the public if needed) upholds self-determination. Self-determination, which involves personal choice, is a fundamental principle of contemporary health ethics.4
Psychiatric rehabilitation in the past
Psychiatric rehabilitation has historical roots in the early 19th century. People with mental illness were liberated from prisons and poor homes and cared for in asylums. These asylums rapidly became large custodial institutions. By the mid-20th century, de-institutionalization had begun—people with mental illness were removed from institutions and integrated into the community.5
One of the first formally recognized psychiatric rehabilitation interventions was social skills training. This was begun in the 1960s and is still used and shown to be effective.6
Another early intervention associated with psychiatric rehabilitation is the clubhouse. In the early stage of de-institutionalization, when there were not enough services in the community, people with mental illness self-organized in New York City to establish the first clubhouse—Fountain House. This clubhouse provided social rehabilitation, and later also provided effective residential and vocational psychiatric rehabilitation.7
Psychiatric rehabilitation today
There are now many more effective psychiatric rehabilitation practices. These range from illness management and recovery, through supported education, to supported employment, and more.8
Recently, the effectiveness of psychiatric rehabilitation has been enhanced by integrating its practices, as well as integrating with related practices. For instance, supported employment has been combined with supported post-secondary education to secure skilled work for people with serious mental illness.9 And vocational rehabilitation has been combined with cognitive remediation, which is a set of psychological practices with computer exercises that help people overcome cognitive impairments such as attention and memory problems.10 This latter combination improves cognitive ability and success in finding, getting and keeping work.11 And psychiatric rehabilitation has also been combined with electronic technology to support effective functioning in independent housing settings, such as by use of a simulated interactive apartment to help prepare people to cook and clean in an apartment.12
Future of psychiatric rehabilitation
What might the future bode for psychiatric rehabilitation? The following scenario may be helpful in conveying possibilities for a person receiving psychiatric rehabilitation services in the future.
Imagine Ray Hope, a 23-year-old man who was diagnosed with schizophrenia after a first psychotic episode at age 18 during his first year of college. That episode lasted a couple of months and was treated effectively at home with antipsychotic medication and cognitive-behavioural therapy.
Ray returned to college with supported education, using his smartphone to download and use cognitive remediation applications for effective schooling. He was guided in this by his psychiatrist and mental health care team, as well as by his college counsellor. Before Ray’s college graduation at age 21, the college counsellor collaborated with a supported employment agency to facilitate Ray’s transition to the skilled job of his choice.
Related ResourcesTwo relevant books that I have recently edited may be helpful to readers:
Ray was offered and accepted a work opportunity in a rural location, where he continued to use his smartphone to practice cognitive remediation. He also used the smartphone to remain in e-contact with his psychiatric rehabilitation practitioner, who helped him train in social skills with new people. This made it easier for Ray to acquire friends in the rural environment, where such social support is particularly important. Ray is thus satisfied and successful in his rural environment of choice.
In order for such a scenario to become reality, the workforce in the mental health care sector should be further trained in psychiatric rehabilitation; as part of that, psychiatrists should become better informed about and more supportive of psychiatric rehabilitation, which is still lacking in Canada and elsewhere although there is some progress on that.13 Also, access of service users to psychiatric rehabilitation should improve, such as in rural and remote communities, likely by using technology such as computer-based secure video.14 And funding for psychiatric rehabilitation should be obtained and protected, as has been done in a few jurisdictions, such as Israel where it is legislated and regulated separately from other mental health care.15
About the authorDr. Rudnick is an Associate Professor in the Department of Psychiatry at the University of British Columbia and the Medical Director of the Mental Health and Substance Use Services of Vancouver Island Health Authority. He is a Commissioner of the international Commission for Certification of Psychiatric Rehabilitation Practitioners
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- Anthony, W.A., Cohen, M., Farkas, M. & Gagne, C. (2002). Psychiatric rehabilitation, 2nd ed. Boston: Boston University, Center for Psychiatric Rehabilitation.
- Rudnick, A. (2002). The goals of psychiatric rehabilitation: An ethical analysis. Psychiatric rehabilitation Journal, 25(3), 310-313.
- Davidson, L., Rakfeldt, J. & Strauss, J. (2010). The roots of the recovery movement in psychiatry: Lessons learned. Chichester, West Sussex: Wiley.
- Kurtz, M.M. & Mueser, K.T. (2008). A meta-analysis of controlled research on social skills training for schizophrenia. Journal of Consultation and Clinical Psychology, 76(3), 491-504.
- Schonebaum, A. & Boyd, J. (2012). Work-ordered day as a catalyst of competitive employment success. Psychiatric Rehabilitation Journal, 35(5), 391-395.
- Corrigan, P.W., Mueser, K.T., Bond, G.R., Drake, R.E. & Solomon, P. (2008). Principles and practice of psychiatric rehabilitation: An empirical approach. New York: Guilford.
- Rudnick, A. & Gover, M. (2009). Combining supported education with supported employment. Psychiatric Services, 60(12), 1690.
- Wykes, T., Huddy, V., Cellard, C., McGurk, S.R. & Czobor, P. (2011). A meta-analysis of cognitive remediation for schizophrenia: Methodology and effect sizes. American Journal of Psychiatry, 168(5), 472-485.
- McGurk, S.R. & Wykes, T. (2008). Cognitive remediation and vocational rehabilitation. Psychiatric Rehabilitation Journal, 31(4), 350-359.
- Corring, D., Campbell, R. & Rudnick, A. (2012). A smart apartment for psychiatric inpatient. Psychiatric Services, 63(5), 508.
- Rudnick, A. & Eastwood, D. (In press). Psychiatric rehabilitation education for physicians. Psychiatric Rehabilitation Journal.
- Rudnick, A. & Copen, J. (2013). Rural or remote psychiatric rehabilitation (rPSR). Psychiatric Services, 64(5), 495.
- Aviram, U., Ginath, Y. & Roe, D. (2012). Mental health reforms in Europe: Israel's rehabilitation in the community of persons with mental disabilities law: challenges and opportunities. Psychiatric Services, 63(2), 110-112.