Guiding Principles of Psychiatric Rehabilitation

The guiding principles of psychiatric rehabilitation comprise a set of rules that can be applied to specific situations in order to achieve the goals and reflect the values of the field. In a sense, they constitute "rules of thumb" that PsyR practitioners can refer to when faced with important decisions. The principles are important tools for providing day-today guidance in clinical situations and for systematizing the practice of PsyR.

Although the higher order values and goals are widely shared by PsyR practitioners, there are still some questions about the application of specific principles. These differences are reflected in the formulations of PsyR principles that have been put forward in the discipline's short history (Anthony et al., 2002; Anthony & Nemec, 1983; Cnaan et al., 1988, 1989, 1990; IAPSRS, 1996). Rather than outright disagreement on these principles, professionals in different settings often prioritize principles differently. This repri-oritization is often a response to real differences that exist between settings or unique situations. For example, in order to justify billing criteria, in some treatment settings staff are required to focus on the consumers' symptoms and deficits when writing clinical notes, rather than on their strengths. As you will see, this emphasis on symptoms and deficits violates the principle of focusing on an individual's strengths. Regardless, for these practitioners a refusal to comply with billing requirements might jeopardize the existence of PsyR services in general. In this paradoxical case, the best response might be to avoid emphasizing strengths when writing chart notes, but still emphasize strengths in actual practice.

As you review the 13 guiding PsyR principles discussed next, consider how they relate to the goals and values of PsyR.

1. Individualization of All Services

This principle means that rehabilitation goal formulation, assessment, and service provision respond to the individual needs and desires of the client. Because it allows each person to develop in the way he or she desires, individualization of services is a very important element of the recovery process. Because many PsyR services are carried out in groups, strict adherence to this principle is very important. Notice how the following supported employment (SE) program is designed to ensure individualization of services and how the curriculum is adjusted depending on the needs of members:

The SE program at Shore House offers a 6-week Vocational Exploration group. The curriculum for this group includes a review of each member's past experiences, including identification of their occupational values, skills, interests, and preferences. The final step for each group member is the development of a vocational goal. A new member, Arthur, wants to get a job and believes he will need the support of the job coach to secure and maintain employment. After several meetings, the job coach is satisfied that Arthur knows what kind of job he wants. Rather than spend 6 weeks in the group to gain information he already has, Arthur will begin working with the job coach immediately on job development.

2. Maximum Client Involvement, Preference, and Choice

This principle is related to the very personal nature of recovery and rehabilitation. Each person has a unique set of preferences, values, and aspirations. Goals or services that are selected for the consumer by the practitioner or anyone else for that matter are meaningless. Consider the following situation that confronted Sharon. How would you feel in her shoes? Or, how would you feel if you were her counselor?

Sharon and her counselor Ann have completed work on her rehabilitation plan. Sharon's rehabilitation goal is to get a job doing clerical work. All of the interventions described in the plan are related to job acquisition (contacting employers, practicing interviewing, etc.). At her team meeting, Ann shares Sharon's plan with other staff. Some members of the team believe that before Sharon works on getting a job she needs to become more outgoing. Ann reminds them that there are many clerical jobs in quiet offices where workers are not expected to be outgoing, but the team thinks it would be good for her and Ann is pressured to change the plan. When Ann and Sharon meet to review and sign the plan, Ann explains that the team agreed that Sharon should volunteer to run the community meeting three times a week for the next 3-month period, and then, if she's more comfortable socializing, she should resume her work goal. Ann decides not to tell Sharon that she is very much against this plan. Despite feeling that she is not respecting Sharon's choice, she rationalizes this by thinking that running the community meeting may actually help Sharon.

3. Partnership between Service Provider and Service Recipient

To assist a person with the rehabilitation and recovery process, the PsyR practitioner first needs to establish a positive connection with the person that is characterized by mutual respect and trust (Fox, 2000, 2004a, 2004b). It may take considerable time and effort to build such a working relationship. Once established, the relationships between PsyR practitioners and the people they serve are true partnerships (Fox, 2000, 2004a, 2004b). In other words, both parties—the consumer and the provider—work together to develop effective rehabilitation strategies. The perspectives of both of these participants are viewed as valuable and essential to the work. Practitioners bring specialized knowledge, skills, and techniques to the relationship; and consumers bring their experiences and a unique understanding of their own needs and preferences.

Larry, who has been a consumer of mental health services for many years, has had some negative experiences in his past relationship with staff members. He doesn't feel that they always understand his point of view and has sometimes felt that they pressure him to sign treatment plans and attend groups that don't pertain to his needs. He is skeptical when he meets Nicole, who introduces herself as his new counselor. What could this young woman possibly know about his life and his dreams? Nicole takes the time to get to know Larry. She encourages him to talk about himself and his interests. She puts in considerable time and effort to help him resolve an ongoing problem he has been having with his landlord. After several months Larry begins to think that Nicole really is concerned about him. When they begin discussing his rehabilitation plan, he is pleased that she encourages him to do most of the talking about his goals. She does offer helpful suggestions, but never tries to talk him into doing something that he's not interested in.

4. Normalized and Community-Based Services

Wolf Wolfensberger, whose work was primarily with people who had developmental disabilities, coined the term normalization. Wolfensberger (1983) describes normalization as the promotion of valued social roles. Worker, student, parent, and neighbor are positive social roles that are valued in our society. Psychiatric patient and group home resident are examples of social roles that are devalued. PsyR services are designed to assist people in taking on and succeeding in valued social roles.

Normalized services are appropriate to the person's age, sex, culture, and so forth. For example, in a PsyR program you would not speak to the adults served as if they were children, or ask them to do finger paintings and then display their work on the wall. In normalized residential settings, consumers live in decent, safe neighborhoods; have access to transportation, shopping, and other community resources; interact with neighbors; and participate in community activities. In contrast, institutional settings and group homes in socially isolated locations would not assist consumers in developing valued social roles and would thus be inconsistent with this guiding principle.

5. Strengths Focus

PsyR services and practitioners recognize and build on an individual's strengths rather than focusing on his or her weaknesses or deficits. This can be a difficult task for both consumer and practitioner. Consumers who have a long history of psychiatric hospitaliza-tions are accustomed to professionals focusing on their symptoms and problems. When asked "What are your strengths?" they are often at a loss. Initially, practitioners may also have difficulty seeing past psychotic symptoms and social deficits such as extreme withdrawal. However, PsyR programs typically allow consumers and practitioners to develop relationships around work and recreational activities. These experiences encourage practitioners to relate to consumers as they would to a colleague or friend, and to focus on what a consumer can do and likes to do. Perhaps this principle is best illustrated by the following professional descriptions of the same individual:

Joan is a psychiatric nurse who sees Peter once a month for medication maintenance group. In a chart note she describes Peter as appearing depressed and withdrawn with poor eye contact and constricted affect. Phil is a vocational rehabilitation counselor who is working with Peter in a supported employment program. His chart note, written on the same day as Joan's, describes Peter as a diligent worker who completes assigned tasks and communicates effectively with his supervisor. Both descriptions may be accurate and are appropriate to the professional's function. Joan's note may assist the psychiatrist in making a helpful medication adjustment, whereas Phil's PsyR assessment helps him determine that Peter's vocational rehabilitation goals are being achieved.

This emphasis on consumer strengths has been championed by the work of Charles Rapp and his colleagues at the University of Kansas (Rapp, 1998).

6. Situational Assessments

Doing situational assessments rather than overall assessments means that the rehabilitation process focuses on the skills and modifications necessary for the client to function successfully in the environments (i.e., situations) of his or her choice. This is in contrast to doing a global assessment unrelated to specific client goals. For example, consumers attending a vocational readiness group may have markedly different employment goals. Sarah wants to get a job as a retail salesperson, while Tony would like to pursue work as a laboratory technician. Doing a general assessment of work readiness skills (e.g., ability to follow directions and complete assigned tasks) is not the best way to predict what they will need to succeed in their chosen jobs. The best way to assess their ability to meet the requirements of their chosen career is to observe them completing relevant tasks in these very different environments. It is likely that focusing on interpersonal skills will be crucial for success for Sarah. The ability to carry out precise measurements and record results will be important for Tony's chosen line of work.

7. Treatment/Rehabilitation Integration, Holistic Approach

This means that PsyR services and practitioners do not separate the treatment and rehabilitation processes. Rather, the client is viewed as a complex individual, taking into account all the aspects of his or her life impacted by these processes. The term treatment usually refers to symptom relief, while rehabilitation usually refers to overcoming barriers and the pursuit of goals. A modern understanding of PsyR views these as complementary endeavors, although historically medical and rehabilitation professionals have not always seen them as such.

Consider the issue of an essential component of the treatment of severe and persistent mental illness, compliance with psychotropic medication. A regimen of psychotropic medication is prescribed by a physician for relief (treatment) of psychotic symptoms. What is the role of rehabilitation in this intervention? On the face of it, one might say it is a simple issue of patient compliance or noncompliance with physician recommendations. However, consumers need knowledge and skills to comply with a medication regimen. In addition, they need to monitor their symptoms and side effects in order to communicate this information to their doctor. This is where rehabilitation can be of assistance to treatment. An individual's ability to monitor and share appropriate information about symptoms, medications, side effects, and so on, can be improved through psychoeducation (Pratt & Gill, 1990). Explicit training can be implemented to teach or increase these skills, such as instructional curricula developed by various groups, most notably Liberman and his colleagues (1993) at UCLA.

Another important point to consider is that rehabilitation goals may be hampered if treatment efforts are unsuccessful. Conversely, successful treatment should promote rehabilitation goals. Thus, treatment and rehabilitation are complementary and interdependent efforts.

8. Ongoing, Accessible, Coordinated Services

PsyR services should be unlimited with respect to time (e.g., there should not be a prescribed time length for services). They should be easily accessible and be coordinated to ensure availability and avoid duplication. As discussed in Chapter 2 and elsewhere in this book, not everyone experiences mental illness in the same way. Nor do the resulting service and support needs remain consistent over time. PsyR programs must be designed to accommodate the varied and changing needs of individuals who may require different levels of services during different phases of their illness. A clubhouse member may benefit from ongoing involvement with the program even after returning to full-time employment. Such involvement may take the form of a "graduate" group gathering one evening a week or occasional attendance at clubhouse-sponsored recreational activities on the weekends. For many consumers, continuous access to a PsyR program, and practitioners and peers whom they trust, is an essential ingredient for recovery.

Ruth Hughes, formerly executive director of IAPSRS, points out that for many consumers the issue is not membership for life but access for life. This means that "Just as we need to increase services, we also need to facilitate decreasing services and helping people move on when they no longer need us as much" (personal communication, August 31, 1998). Consumers who know that, if needed, they will always be welcome to return will have more courage to explore new opportunities.

Coordination of services is also a crucial aspect of successful community integration. Consumers may be involved with several different PsyR or mental health agencies at the same time, or may need to be referred to different service providers as their needs change over time. Case management services (see Chapter 7) are one effective strategy for accomplishing this coordination. Consider the problem of service coordination described in the following example:

Laura is a quiet and somewhat passive young woman who seeks to please both her family and the various practitioners who work with her. She sees a psychiatrist once a month at a community mental health center where she and her family are also involved in a family psychoeducation and support group. Currently, the group facilitator is encouraging Laura and her family to work toward their stated goal of Laura returning to college. Meanwhile, the free-standing clubhouse program that Laura attends three times a week is in the process of placing her in a full-time position through their supported employment program. Laura is ambivalent about her future and becoming increasingly anxious about working toward conflicting goals.

Clearly the lack of service coordination described above can interfere with successful rehabilitation. Even more important, more work needs to be done to help Laura clearly determine what she wants. Such situations can result in both a waste of professional resources and can set up consumers for failure.

9. Vocational Focus

Work is an important aspect of life and should be available to everyone who wants it. Joe Marrone, a nationally known vocational services advocate believes that not working is not really a viable choice, "I Think You Should Work, That's What I Think" is the title of one of his regular talks; he points out the true drawbacks of not working including poverty and isolation (Marrone & Golowka, 2000). In other words, all adults, with or without disabilities, should work. PsyR practitioners do not question the ability of someone to work, but rather assist the individual to acquire the skills, resources, and supports necessary for success. PsyR practitioners know that it is the absence of skills rather than the presence of mental illness that create barriers to successful living.

A good example of this principle is the case study in Chapter 9 covering vocational rehabilitation. Even though Carl had failed repeatedly at his attempts to work, the program continued to support him in pursuing his goal. Rather than focusing on the failures, the job coach focused on his strengths, skills, and interests and explored the supports that might help him to succeed. Maintaining a consistent focus on the vocational goal eventually leads to vocational success.

10. Skills Training

PsyR services and providers should be capable of helping people in recovery acquire the skills necessary to function successfully in the environments of their choice.

Skills training often encompasses much more than the specific skills one needs to work on a job. We are often unaware of the skills we employ to negotiate everyday situations. Consider the set of skills that need to be mastered just to get through a job interview. The effective PsyR practitioner identifies the skills his client needs to succeed and then helps him or her acquire them. Role playing the interview might reveal that the client speaks too softly and does not make eye contact. The practitioner might role-play these skills for the client, teach the skills, and then provide opportunities for practice until the practitioner and the client feel the skill has been mastered.

11. Environmental Modifications and Supports

PsyR services and providers help people with disabilities access or negotiate the environmental modifications and supports necessary to function successfully in the environments of their choice. Environmental modifications and supports can take many forms.

For someone in a wheelchair, providing a ramp into a building is an important modification. For someone with mental illness, a change in working hours to accommodate a public transportation schedule might be a very important modification.

12. Partnership with the Family

Families are, in many cases, the most important and stable support system for persons with severe mental illness. State-of-the-art psychiatric rehabilitation includes family members as partners whenever possible if it is acceptable to the consumer. Thus, the best PsyR programs will have family members, together with consumers, on advisory and governing boards of directors. At the same time, consumer involvement is promoted among any services offered to families. Today, family psychoeducation in the form of ongoing multiple family groups with the consumer present is recognized as an evidence-based practice.

This strategy, which is described in more depth in Chapter 13, achieves important outcomes for the consumer as well as the family. PsyR professionals and agencies promote communication with interested family members, with the consent of consumers. For example, family members who inquire about their family member who is receiving PsyR service are often denied information for reasons of confidentiality and lack of a signed release. Best practice in this case means having an appropriate release of information or consent signed prior to a family member asking for information. Given that numerous consumers live with their families, it is critical that family members become engaged as partners in the processes of rehabilitation and recovery. For more information about the role of the family in PsyR, see Chapter 13.

13. Evaluative, Assessment, Outcome-Oriented Focus

To ensure that services are effective, providers must continuously evaluate and assess the outcomes they achieve and the quality of their services on both an individual and a system-wide level. Continued evaluation and assessment are very important, for instance, to identify changes in the needs of the population that programs are designed to serve. These population changes are much more common than might be imagined. Consider the apparent increase in the number of persons with a severe mental illness and a substance abuse problem. Since few of the newly deinstitutionalized persons had substance abuse problems in the 1960s, there was little need for substance abuse services. Long periods of hospitalization may have reduced the possibility of substance abuse for many of these people. After deinstitutionalization, when most persons with severe mental illness entered the community, professionals became aware of increasing numbers of consumers with substance abuse problems (Caton, 1981; Drake & Wallach, 2000; Pepper, Ryglewicz, & Kirshner, 1981). Facilities that employed program evaluation strategies and regularly monitored their outcomes were the first to identify this new need in their treatment population and begin to devise specifically designed services for them.

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