The Values of Psychiatric Rehabilitation

The values that underlie most, if not all, PsyR services relate directly to the goals that PsyR tries to achieve. Values are general attitudes that influence the professional's behavior in many ways. In fact, PsyR practitioners may hold these values without articulating them since they are embedded in the designs of the programs they work in and the service strategies they carry out. As you review the following five PsyR values, consider how they relate to the goals of PsyR.

1. Everyone Has the Right of Self-Determination, Including Participation in All Decisions That Affect Their Lives

In PsyR facilities this value is often referred to as empowerment. While this term's usage is nearly universal, because it encompasses so much, there is still no generally agreed-on definition of empowerment. Community psychologist Julian Rappaport (1987) characterized the term empowerment as conveying ". . . both a psychological sense of personal control or influence and a concern with actual social influence, political power, and legal rights" (p. 121).

Consumer involvement and empowerment directly relate to the importance of the recovery process. As Deegan (1988) pointed out, the essence of recovery is the individual's reestablishment of a self-concept that takes the mental illness into account. This is in contrast to the notion that the services provided constitute the rehabilitation itself. Instead, the services help make the rehabilitation process available, attractive, and possible for the individual with a disability who must do the very real work of self-change. As Deegan (1988) put it:

" . . . persons with a disability do not "get rehabilitated" in the sense that cars "get" tuned up or televisions "get" repaired. They are not passive recipients of rehabilitation services. Rather, they experience themselves as recovering a new sense of self and of purpose within and beyond the limits of the disability. (p. 12)

How are these involvement and empowerment goals achieved for persons with severe mental illness? Many varied and innovative service delivery strategies are designed, developed, and refined in an effort to accomplish these goals.

One important aspect of involvement and empowerment concerns consumers' knowledge about their condition and their treatment. A study by Warner, Taylor, Powers, and Hyman (1989) examined the effect of labeling consumers as mentally ill. The authors had hypothesized that consumers who were accepting of their mental illness diagnosis would have lower levels of functioning. In fact, they found the opposite was true and concluded that empowerment, in the form of shared knowledge, may help reduce psychiatric disability.

Pratt and Gill (Pratt & Gill, 1990; Gill & Pratt, 1993) developed empowerment and involvement strategies for day treatment services that included sharing knowledge, power, and economic resources with consumers. From these starting points consumers were encouraged to extend their prerogatives to other aspects of their programs. These strategies produced greater consumer involvement with their program, increased acceptance and awareness of mental illness, and improved outcomes.

Another important aspect of self-determination or empowerment is ensuring that people with psychiatric disabilities are allowed to make decisions about their own lives— even if the decision could lead to a negative outcome. Another way of expressing this idea is that all people should have the right to take risks in their lives. Many well-intentioned practitioners struggle with consistently applying this value. They encourage consumers to make decisions, but also want them to play it safe and avoid any actions that could lead to a failure or setback. While it is important to be sure that people understand the potential consequences or their decisions and behaviors, it is ultimately the consumer's choice. For example, a person may feel ready to take on a full-time job, while staff members believe the person should take a less stressful part-time position. Sometimes, options that seem risky work out better than expected, whereas at other times the setback predicted by staff does occur. In either case, people should be empowered to direct their own lives and have experiences that will help them learn about their potential as well as their limitations.

While everyone uses the term there is still a good deal of debate about how to exactly define empowerment. One way of defining something is to formulate a working definition of it so that it can be measured. With input from several consumer groups around the country, Rogers, Chamberlin, Ellison, and Crean (1997) have begun development of a scale designed to measure empowerment. They suggest that empowerment is made up of three parts. The first element of empowerment is self-esteem/self-efficacy. This can be thought of as optimism and a sense of control over the future. The second element involves possessing actual power. The final element of empowerment, they suggest, is made up of righteous anger and community activism. It is important to recognize that these elements of empowerment describe characteristics of empowered people. Similar to the concept of recovery, empowerment is something that must come from within the individual, rather than something done to or for an individual.

2. PsyR Interventions Respect and Preserve the Dignity and Worth of Every Human Being, Regardless of the Degree of Impairment, Disability, or Handicap

This core value underlies every aspect of PsyR practice. People are in no way lessened as human beings by their illness. If asked, most service providers and consumers would personally endorse this position. Despite these socially correct declarations, the persistent stigma against people with mental illness suggests that in reality this is not a widely held value.

A lack of dignity or worth is conveyed in various ways, many of which are very subtle. Consider a setting where the service recipients are addressed by their first names but the staff members are only addressed by their titles or surnames. The message in such behavior is very clear; the service recipients have low status while the staff members have high status. This same message may be conveyed in other ways as well. For example, when different rules apply to program staff and service recipients regarding use of program areas (conference rooms where only staff are allowed to congregate, separate bathrooms for service recipients and staff, etc.). While individual situations like these are subtle, each sends a message that service recipients have low status and reduces their dignity.

If numerous such situations exist together in an insensitive environment, it conveys a clear message that persons with severe mental illness who require services have less worth than the persons who staff the program. Most of these situations, when they exist, are unintentional. The concept of staff bathrooms and lunchrooms is relatively common in many settings and does not carry a negative message. Most people address their own physician by the title "doctor." Nevertheless, for persons with mental illness an accumulation of these situations combined with societal stigma conveys a strong message that they are less valued by society. Wolf Wolfensberger's (1983) efforts to develop surveys and scales to identify these dignity-reducing situations are important simply because they are often subtle, unintended, and may be essentially invisible to the staff.

3. Optimism Regarding the Improvement and Eventual Recovery of Persons with Severe Mental Illness Is a Critical Element of All Services

Every person, regardless of his or her symptoms or handicaps, has the capacity to benefit from services. Real optimism on the part of service providers generalizes to the service recipients. Of course, the ultimate optimistic stance is represented by the concept of recovery described earlier in the chapter.

At the same time, providers who lack optimism regarding the potential of consumers may be hard pressed to maintain the requisite level of motivation to effectively carry out their functions. Worse, even the most symptomatic individuals are aware of when a practitioner believes that they will not achieve their goals.

The practical effects of a lack of optimism were often exemplified by the inadequate and inappropriate treatment provided for persons with severe mental illness by the traditionally trained staff of many community mental health centers (Torrey, 2001). Based on their training, these staff were often pessimistic about the long-term prognosis of persons who lacked appropriate ego functioning and the insight to benefit from treatment. Because of the pervasive belief that these persons could not improve, treatment resources were often allocated to programs providing services for persons with less severe conditions who could benefit from more psychodynamically oriented treatments. Persons experiencing severe and persistent mental illness, labeled "chronics," were often treated by the least trained staff, given minimal psychiatric time, and given minimal levels of supplies, space, and support staff.

4. Everyone Has the Capacity to Learn and Grow

This value is clearly a corollary of the value of optimism. The core message of this value is that all people, regardless of their level of disability, can benefit from modalities such as skill training and education. The presence of a mental illness does not preclude someone's ability to learn and grow.

Consider what happened to a consumer named William who had been in a PsyR day program for 5 years after spending the previous 13 years in a psychiatric hospital. William, who was always neat and well groomed, was almost entirely noncommunicative. One thing that he did communicate was a desire to work. Previous attempts at getting William to be more outgoing had all ended in failure. While he did not communicate, William did seem to like to be around people. Reviewing past failures, a new case worker hit on an idea. If William could learn to use a few phrases and operate the equipment, he could work as an elevator operator, a job for which some openings existed. William responded very positively to this idea. He learned to greet people and ask them what floor they wanted. He also learned to operate the elevator, paying particular attention to the doors and to whether it stopped evenly with the floor at each level. The staff were amazed that William could learn these things after years of being almost a recluse. William held that job for many years, rarely saying more than "Good morning!," "What floor?," and "Watch your step!"

5. PsyR Services Are Sensitive to and Respectful of the Individual, Cultural, and Ethnic Differences of Each Consumer

Severe mental illness knows no cultural or ethnic boundaries. Providers of PsyR services must be prepared to aid any individual experiencing these conditions. Sensitivity to cultural and ethnic differences is necessary when we consider that the task of PsyR

is essentially reintegration with the consumer's community of choice. To successfully accomplish this goal, it is the responsibility of the practitioner to be sensitive to the particular beliefs, mores, and customs of the community in question. In short, the practitioner must become culturally competent and ensure that the services provided are also culturally competent. Tales abound of the kinds of social faux pas that occur when professionals make incorrect judgments about the consumers they serve because of a lack of knowledge of their culture. For example, when a person in the United States does not look at another person directly they might be suspected of having something to hide. However, looking at someone directly is considered rude or aggressive in some cultures.

This is an especially sensitive area for PsyR practitioners because they must constantly deal with the issue of societal stigma toward the consumers they serve. The constant problem of stigma helps to keep the practitioner aware of the importance of respectful communication and behavior. In one sense, having a severe mental illness constitutes a unique cultural identity in itself. The struggle to help consumers free themselves from the role of "mental patient" may be aided by increased respect and awareness for the consumer's ethnic and cultural background.

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Responses

  • shaun
    What are the defining values held by PsyR professionals?
    7 months ago
  • Mebrahtu
    What is the value of psychosocial rehablitation?
    3 months ago

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