Principles and Practice of Psychiatric Rehabilitation: An Empirical Approach

Psychiatric rehabilitation has come of age. With the realization that persons with psychiatric disabilities can recover and lead satisfying lives of quality, the modalities of psychiatric rehabilitation have become the paving stones on the road to recovery (1) . Psychiatric rehabilitation consists of teaching skills and designing supports that enable mentally disabled individuals to achieve optimal psychosocial functioning in the meaningful and normalizing realms of community life with as minimal intrusion of symptoms as is possible. These realms include work, education, socializing, friendships, spirituality, independent living, illness self-management, family, recreation and leisure, sexual intimacy, and citizenship.

The authors of this remarkable textbook, Corrigan, Mueser, Bond, Drake, and Solomon, are undisputed leaders in the field of psychiatric rehabilitation. They have made important contributions to the literature on a wide variety of rehabilitative interventions: supported employment, assertive community treatment, dual diagnoses, behavioral family therapy, family psychoeducation, consumer-operated services, anti-stigma programs, social skills training, and systems of services. While this broad sweep of interventions would ordinarily require a book with chapters contributed by specialists in the field, the five authors of this book have pooled and coalesced their expertise and experience into a reader-friendly, well-integrated, and scholarly text that holds together as though it was written by a single person. This encyclopedia of validated best practices should be a sturdy and ready reference on the shelf of all practitioners who work with the severely mentally ill.

In a veritable feast of nutritious rehabilitative services, the chapters are devoted to functional assessment, illness self-management, case management, adherence to medication and shared decision making, housing, employment and education, social functioning, social skills training, family interventions, cognitive remediation, and cognitive-behavioral therapy for psychotic symptoms. Considerable attention is given to those treatments and services that are evidence-based. As in the very best textbooks, the authors provide exhaustive documentation of the growing research base supporting the empirical validation of rehabilitative services.

Supported employment is an exemplar of evidence-based practice. Studies have shown that employment specialists linked to multidisciplinary treatment teams in community mental health settings are able to assist upwards of 50% of mentally disabled persons who are motivated to find jobs in the competitive community sector. As a person-centered vocational service, employment specialists encourage shared decision making in the job search with 18 to 20 other patients. The program’s philosophy assumes that support must be continuous and indefinite in duration to help patients obtain and keep jobs. Employment specialists collaborate with employers on job training, solving various problems that emerge in the work setting, and motivating patients to return to the job search after losing or leaving a job.

Going beyond a taxonomy of treatment services, this book includes issues that are timely and controversial. One of these issues is the criminalization of the mentally ill, for which an entire chapter is devoted. Rehabilitation is surfacing in small but important ways in communities around the country to provide comprehensive, coordinated, and continuous services as an alternative to the imprisonment of mentally ill offenders. Some of the efforts in this direction include making psychiatric treatment more accessible in the community, diversion from jails to treatment facilities, use of modules for social and independent living skills training (2) , preparation for reentry into the community, contingent parole, and community support programs.

From this point of view, psychiatric rehabilitation is addressing the dreams and needs of the incarcerated and mentally ill for freedom, choice, and participation in community life that mainstream psychiatry has ignored. Throughout the country, psychiatrists are being hired to work in prisons and forensic facilities, often at extraordinarily high salaries, to conduct diagnostic evaluations and prescribe medication (3) . From a societal and ethical point of view, psychiatrists working in prisons are “hired guns,” treating mentally ill offenders with psychotropic drugs to reduce symptoms, victimization, and disturbing behavior; in short, to promote security and equanimity in punitive institutions. Rehabilitative values and services are beginning to make an impact in courts, jails, and prisons, because patient rights and consumer advocacy organizations understand that medications cannot teach mentally ill persons how to live successfully and productively in community life. For psychiatrically disabled persons to thrive after release from prison, they will need skills and support that will permit them to swim, not sink, in the often rough waters of life after incarceration, including stigma, homelessness, segregated living arrangements, obstacles to employment, and financial duress.

Case examples are sprinkled throughout the text to illustrate the techniques being described. To the great credit of the authors, these vignettes highlight the key role of the therapist-patient relationship as the prime mediator of the effectiveness of rehabilitation. Even today, in our high-tech, accountability-obsessed, and patient-empowered times, that oldest of relations between patient and therapist—infused by trust, confidence, concern, and respect—continues as a mainstay of evidence-based practices. In the face of residency training and public mental health, where brief “med checks” are the mode for treating the seriously mentally ill, the authors strip away the veneer of empathic detachment and convincingly demonstrate how psychiatric rehabilitation carries the torch of the therapeutic alliance. It is regrettable that the vast majority of psychiatrists would be hard-pressed to describe psychiatric rehabilitation, much less be able to use it.

We can all look forward to a sequel to this splendid volume, in which the authors report how evidence-based practices can be disseminated, adapted, and adopted by agencies and clinicians throughout the world, moving from effectiveness studies to practice-based evidence. Practice-based evidence emerges when clinicians realize that controlled treatment trials report statistically significant differences between means of data in large samples of patients. Conclusions about evidence-based practices do not readily transfer to the individual patient. One cannot make treatment decisions about individuals who are not “statistics.” As the science and practice of rehabilitation continues to prosper, recovery from serious mental illness will become the rule rather than the exception.