Psychiatric Rehabilitation Methods 1 9 Richard Warner

of the York Retreat, brought us the principle of Principles of Social Intervention minimal use of coercion and the understanding that patients’ self-control can be enhanced by Psychosocial rehabilitation offers a number of respectful treatment in a home-like environment program models, refi ned over years of research and by rewards rather than punishment. and practice, which aim to improve the social Eighteenth-century private madhouse operators inclusion of people with serious mental illness and tried to outdo one another in optimism, by extol- to reduce the symptoms of illness and the handi- ling the likelihood of recovery from mental ill- cap which they create. But the fi eld is more than a ness if only family members would seek their series of programs. Rehabilitation practice is based services in a timely way (Warner 2004 ) . These on a set of principles or values which we inherit principles of moral treatment were lost during the from 200 years of social psychiatry. These princi- era of large asylums in the nineteenth century, but ples, set out in Table 19.1 , have been “rediscov- the consumer-driven US mental hygiene move- ered” in the great social movements in psychiatry ment, which established institutional reforms, of the past two centuries, the latest of these being reintroduced the notion of therapeutic optimism, the Recovery Model or Movement. The fact that and demonstrated the importance of collaborat- these values have been rediscovered on several ing “with leaders in education, law, religion and occasions tells us that they have been periodically social work” (p. 743) (Beers 1932 ) . abandoned, so it is important for us to recognize The Great Depression brought a return to and accept the centrality of these principles to the institutional confi nement, but the post-WWII work that we do. The best treatment models avail- northern European social psychiatry revolution, able will not thrive in a treatment setting which which preceded the introduction of antipsychotic neglects the values on which they are based. drugs, opened the locked asylum doors, abol- Moral treatment, made vivid by images of ished mechanical restraints and demonstrated the Pinel striking the chains from the inmates of the benefi ts of early discharge from hospital and Bicêtre asylum in 1793, but better illustrated by work therapy. British psychiatrists introduced William Tuke’s contemporaneous development the “therapeutic community” into psychiatric hospital wards across the country. Under this approach, staff shared power with patients in the R. Warner , MBBS, DPM (*) running of the hospital units, nurses’ abandoned Colorado Recovery , 2818 13th Street , Boulder , CO 80304 , USA their uniforms, staff and patient roles were blurred and, thus, the concept of patient empow- Department of Psychiatry , University of Colorado , Denver , CO , USA erment was introduced into psychiatry (Warner e-mail: [email protected] 2004) . The same approach was simultaneously

H.L. McQuistion et al. (eds.), Handbook of Community Psychiatry, 223 DOI 10.1007/978-1-4614-3149-7_19, © Springer Science+Business Media, LLC 2012 224 R. Warner

Table 19.1 Principles of social interventions in psychiatry (Ramon et al. 2007 ) , refers both to the subjective Treatment approach experiences of optimism, empowerment, and Multidisciplinary, fl exible, empowering interpersonal support experienced by people with Reduced reliance on drug treatment mental illness and their informal care providers, Consumer participation in treatment and to the creation of services that engender opti- Family support and education mism about outcome from illness and a support Treatment location for human rights. The roots of the movement may Local and accessible be found in both the consumer movement and in In the community psychosocial rehabilitation. Consumers have Treatment setting reinforced the drive towards empowerment, col- Small, domestic, normalizing laboration, and recognition of human rights. Encouragement of individual self-control Rehabilitation professionals, on the other hand, Reduction of coercion and con fi nement have emphasized the need for services that recog- Involvement of the larger community nize the value of work and the sense of commu- Collaboration with other social agencies Fighting stigma nity in the lives of people with mental illness, and Political advocacy the importance of environmental factors in help- Respect for human rights ing people with psychiatric disorders achieve The importance of client communities their best functioning potential (Jacobson and Empowerment: transfer of power from service providers Curtis 2000 ) . to service users The model calls for the provision of education The value of work about psychiatric disorders as a way to empower Therapeutic optimism consumers to collaborate with service-providers Understanding biological, psychological, social, cultural, in managing their own illnesses. Collaborative and political-economic factors models, such as the psychosocial clubhouse and educational programs that involve both profes- being introduced into community practice in sionals and consumers as teachers, are seen as New York City. Fountain House, the fi rst psycho- important elements of recovery-oriented services. social clubhouse, was founded in the city in 1948 The model has generated renewed interest in by ex-patients of Rockland State Hospital (Leff fi ghting stigma and the creation of user-run ser- and Warner 2006 ) . Members and staff worked vices that offer advocacy, mentoring and peer together to run the program, creating, in the pro- support via such mechanisms as user-run “warm- cess, a form of institutionalized empowerment of lines” (peer-to-peer supportive chat-lines) and people with mental illness which was to long out- drop-in centers (Jacobson and Greenley 2001 ; last the hospital-based therapeutic community. Shean 2007 ) . The 1990s saw an explosion in the number of The scientifi c evidence supports such central psychosocial clubhouses, both in America and components of the recovery model as optimism around the world, and the introduction of another about outcome, and the value of empowerment consumer-driven psychiatric social movement— and peer support. One of the most robust fi ndings the Recovery Model—a central tenet of which is in schizophrenia research is that 20% of those empowerment. At this stage, we may take a look with the illness will recover completely and at the infl uence of the Recovery Model and at the another 20% or more will regain good social value of the psychosocial clubhouse. functioning (Warner 2004 ) . Much recent research suggests that working helps people recover from schizophrenia, and advances in vocational reha- The Recovery Model bilitation have made this more feasible (Leff and Warner 2006 ) . A growing body of research The Recovery Model is covered in detail in supports the concept that empowerment is an Chap. 7 . The model, which is in fl uencing service important component of the recovery process and development in Britain, the USA, and elsewhere that consumer-driven services are valuable in 19 Psychiatric Rehabilitation Methods 225 empowering the person with schizophrenia and work preparedness and assists members in improving outcome from illness (Warner 2010 ) . obtaining employment. (The model is discussed Psychiatric rehabilitation provides a road to in detail in Chap. 30.) From simple beginnings, recovery. The goal of rehabilitation is to help peo- Fountain House in New York City achieved an ple with a disability enjoy the best and fullest life international reputation, receiving hundreds of possible. It offers a route to working, making visitors a year. By 2009 there were 330 club- friends, having fun and taking on responsibilities— houses in 27 countries around the world. Central in short, full citizenship. The person with disabil- components of the model are democratic deci- ity picks his or her personal objectives and the sion-making and governance and the “work- rehabilitation service aims to reduce the disabil- ordered day”—a structured 8-h day in which ity and make goal attainment and recovery members and staff work side-by-side on club- possible. This chapter outlines some of the house work. The clubhouse is a space owned by psychiatric rehabilitation models and approaches the members, not the treatment system (Beard that mental health professionals and others have et al. 1982 ; Macias et al. 2001 ) . Empowerment, developed over the years, incorporating the values treating the person with mental illness with inherent in the Recovery Model and other social respect, absence of coercion (membership must movements in psychiatry. be voluntary), and the importance of work are central principles. The emphasis on work is evident in the employment programs generated by psychoso- Vocational Services cial clubhouses. Initially, these work programs took the form of transitional employment pro- There is good scienti fi c evidence that working grams in which temporary (3–9 months) part- helps people recover from serious mental illness. time job placements were found for members in At a macroeconomic level, we know that outcome local businesses. Job coaches learned how to do from schizophrenia is worse (Warner 2004) and the job, trained the member, and provided long- admissions to hospital of working-age adults with term support to him or her in the position. More psychosis are greater (Brenner 1973) during peri- recently, these placements have taken the form of ods of increased general unemployment. At the continuous supported employment, in which the individual level, numerous controlled studies con- job placement is permanent. The approach has ducted since the early 1990s have identifi ed grown into a successful model with broader reach improved nonvocational outcomes for subjects than the clubhouse. with serious mental illness who are working. Participation in an effective vocational program or having paid employment is associated with Supported Employment and Individual reduced psychiatric hospital admissions, reduced Placement and Support health-care costs and decreased positive and nega- tive symptoms of psychosis. Successful work pro- Supported employment, and its more recent grams lead to increased quality of life, improved refi nement, individual placement and support self-esteem, enhanced functioning, and an (IPS), have been proven effective, in a large num- expanded social network (Leff and Warner 2006 ) . ber of studies conducted in North America and several other countries, with rates generally run- ning from 50 to 75% compared to control rates of The Psychosocial Clubhouse 9–40% in placing and maintaining people with mental illness in competitive work (Bond et al. The psychosocial clubhouse is a consumer-driven 2008) . This vocational approach is discussed in rehabilitation model with a strong vocational more detail in Chap. 25. The core principles of focus which harnesses the benefi ts of client the model include a focus on competitive, rather empowerment to increase members’ skills and than sheltered, employment; rapid job search, 226 R. Warner instead of extended preemployment assessment café, a restaurant, a transportation business, a and training; integration of the vocational and building renovation company and many others, treatment services; paying attention to clients’ with an annual income of $14 million. The family- job preferences; and providing time-unlimited, style Hotel Tritone, one of the early businesses, individual job support (Bond 2004 ) . Inherent in proved to be particularly successful and has been this approach are some important principles of franchised. All of fi ce- and street-cleaning con- social intervention—involving the community tracts for the municipality of Trieste are currently (in this case, employers) in assisting the social awarded to social fi rms. Over 300 people with integration of people with mental illness, using disabilities or disadvantages, half with mental a noninstitutional approach (no sheltered work- illness, are currently employed in the Trieste shops), and showing respect for the person’s cooperatives and earn a full market wage, and preferences and strengths. another 200 people diagnosed as having mental illness hold training positions reimbursed by gov- ernmental stipend (Warner and Mandiberg 2006 ) . Social Firms (or Affi rmative Businesses) The model has spread widely in Italy and inter- est in social fi rms has increased throughout Another vocational model which has gained Europe. By 2005, there were over 8,000 such strength in recent decades is the social fi rm. enterprises in Europe with 80,000 workers, 30,000 Social fi rms, or af fi rmative business as they are of whom had psychiatric or other disabilities. In known in North America, are businesses created Germany, second only to Italy in number of social with a dual mission—to employ people with dis- fi rms, there were over 500 such companies in abilities and to provide a needed product or ser- 2005, with a combined workforce of over 16,000 vice. The model was developed for people with employees, 50% of whom had disabilities. Before psychiatric disabilities in northern Italy in the 1997, there were just six social fi rms in Britain. 1970s and, by diffusion, has gained prominence Since then, with the assistance of the support throughout Europe and Australasia. Independent group Social Firms UK, the number has grown to of European in fl uence, af fi rmative businesses more than 150, nearly half of which are consid- have also developed in North America (especially ered “emerging” social fi rms, meaning that they Canada) and East Asia. Over a third of employ- still use some subsidy and are not yet fi nancially ees in social fi rms are people with a disability or self-sustaining. Catering and horticulture are the labor-market disadvantage. Every worker is paid largest business sectors. Irish Social Firms, in a fair market wage, accommodations are made Dublin, illustrates the importance of business for disabled workers’ needs, and all employees viability. In the 1990s, this consortium operated a have the same rights and obligations. Hard to restaurant, a lunch counter, a wool shop, and a achieve, but important nevertheless, the business furniture store, but these businesses have closed must operate eventually as a viable concern, free in recent years because of the subsidy required to of subsidy. Advantages of the social- fi rm model sustain them (Warner and Mandiberg 2006 ) . include opportunities for empowerment and the Social fi rms may achieve success by fi nding development of a feeling of community in the the right market niche. Many gain a market edge workplace (Warner and Mandiberg 2006 ) . by competing for contracts with public agencies, The fi rst social fi rm was set up in 1973 as a such as hospitals, which often have a special worker cooperative for previously hospitalized interest in the social inclusion of people with dis- patients during the deinstitutionalization of San abilities or a strategic need to be seen to serve the Giovanni Hospital in Trieste in northeastern Italy. public interest. They may also have practical mar- Within 10 years, the business, which employed ket advantages. A cleaning business in Pordenone, workers to clean public buildings, was employing in northern Italy, successfully developed contracts 130 workers. Over the next 20 years, a consortium with public facilities because the unionized of businesses was developed which included a workforce it replaced was relatively ineffi cient. 19 Psychiatric Rehabilitation Methods 227

The market niche may come from workers’ special symptoms, and about their meaning to the indi- qualities. People with disabilities, for example, vidual, can lead to an improvement in symptoms. may have unusual reserves of empathy and It emerges that gently challenging the evidence patience when employed as home health aides. used by people with psychotic disorders to sup- The public orientation of social fi rms can help port their delusions, offering alternative view- them earn contracts through a willingness to points, testing reality, and enhancing coping tackle community problems—such as salvaging strategies can be helpful. This approach is dis- abandoned motor scooters to clean up a run-down cussed in Chap. 13 . A course of treatment may section of the city (Warner and Mandiberg 2006 ) . extend for ten or more sessions. After establish- Social fi rms often select labor-intensive busi- ing a trusting relationship between therapist and ness options to maximize employment while patient, the therapist may gently test the patient’s minimizing capital investment. Common beliefs as in the following illustration: choices include cleaning services; handmade Patient : “The Ma fi a has my house under products, such as wooden toys; organic food surveillance.” production that is not driven by investments in Clinician: “Well, that is possible…. But why do machinery and fertilizer; car washes; and bicy- you think it is the Mafi a? Could it be cle repair. At times, however, a social fi rm con- some other organization? Or is some- sortium may choose to develop a business that thing else happening altogether? How is pro fi table but employs relatively few people could we fi nd out?” (Turkington et al. with disabilities in order to use these earnings to 2006 ) (p. 367). offset other losses (Warner and Mandiberg 2006 ) . Cognitive behavioral therapy has been shown A profi table venture of this type is the consumer- to be effective for persistent psychotic symptoms oriented pharmacy in Boulder, Colorado (Leff in people who are resistant to treatment with and Warner 2006 ) . antipsychotic medication (Wykes et al. 2008 ; Social fi rms offer some advantages over the Pinninti et al. 2010 ) . The goal is not to persuade supportive employment model. For example, they the patient that he or she has a mental illness. provide an opportunity for developing a sense of Rather, it is to reduce the severity of the symptom community in the workplace. A manager of a or the distress it causes. Patients are helped to social fi rm in Trieste described this community identify coping strategies that may reduce both feeling as “a small extended family.” The sup- the cues and reactions to such symptoms as hal- portive atmosphere may explain why the rate of lucinations or delusions. For one person, being transition from social enterprises into competi- alone or bored may be a cue to an increase in hal- tive employment is low in most countries lucinations; he or she can be taught to adopt strat- (Seyfried and Ziomas 2005 ) . Studies show that egies to reduce isolation or boredom. Others may belief in an organization’s social mission enhances learn to reduce auditory hallucinations by hum- worker participation and promotes organizational ming, conversing with others, or even reasoning success (Warner and Mandiberg 2006 ) . with the voices and telling them to go away and come back later. Similarly, a person might be taught to test the reality of delusional beliefs Restoring Strengths and Abilities against the therapist’s interpretation of events and, for example, return to a church social group Cognitive Behavioral Therapy for about which he or she had harbored paranoid Persistent Psychotic Symptoms fears (Tarrier et al. 1999 ) . The approach does not reduce relapse rates in psychosis, but is effective Despite the long-held belief that it is a pointless in reducing distress resulting from positive symp- exercise to try to dissuade people from holding toms (Garety et al. 2008 ) . tenacious delusional beliefs, recent research CBT for persistent psychotic symptoms has reveals that talking to people about their psychotic been incorporated into the American Psychiatric 228 R. Warner

Association practice guidelines for the treatment on functioning is greater in studies that provide of schizophrenia (American Psychiatric Associ- psychiatric rehabilitation in addition to cognitive ation 2004 ) and into the Schizophrenia Patient remediation (McGurk et al. 2007 ) . Most remedi- Outcomes Research Team (PORT) recommenda- ation programs now employ computer-based tions (Lehman and Steinwachs 1998 ) . A recent training among their methods, but such advances review of the literature concludes that we now in technology do not appear to have improved have an effective psychotherapeutic intervention outcomes appreciably. Programs that include for people with schizophrenia (Turkington et al. strategy coaching have greater effects on func- 2006 ) . Clinicians who have become accustomed tioning; this approach targets memory and execu- to simply establishing the existence of hallucina- tive functions by teaching such strategies as tions and delusions in their patients may now problem solving and chunking information to need to pay more attention to the content of these facilitate recall (McGurk et al. 2007 ) . symptoms.

Social Skills Training Cognitive Remediation Social skills training is a method of teaching peo- More attention has been paid, in recent years, to ple with serious mental illness who have social the cognitive symptoms of psychosis—such and emotional skill defi cits how to improve these handicaps as decreased processing speed and basic skills. The approach, which is based on poor attention, concentration, and working mem- behavioral learning principles, was developed by ory. Cognitive impairment, along with positive, Robert Liberman in the 1960s (Liberman 2008 ) . negative, and affective symptoms, is a core fea- The method has enjoyed some popularity in the ture of schizophrenia. The evidence suggests that USA but, although the social skills manual has it is correlated with work functioning, social rela- been translated into 23 languages, it has not been tions and the capacity for independent living and adopted to any great extent in other countries is an impediment to gaining benefi ts from psy- (Liberman 2008 ) . chosocial rehabilitation (McGurk et al. 2007 ) . In a typical course of training, after establish- Forthcoming editions of the Diagnostic and ing a therapeutic alliance and conducting a behav- Statistical Manual for Mental Disorders are ioral assessment, the trainer and trainee will expected to direct more attention to cognitive establish long- and short-term goals for dealing defi cits in psychosis. The increased attention to with a specifi c interpersonal problem and develop cognitive dif fi culties has stimulated greater a scenario to achieve these goals through role- attempts to rectify them. Pharmacological inter- playing with other members of the group. The ventions have shown little effect on cognitive patient is encouraged to perceive how he or she de fi cits (Marder 2006 ) , but cognitive remediation might have handled a situation differently in the programs, employing such strategies as repeated role play and earns positive feedback for improve- practice, teaching to improve cognitive function- ment in skills. When the patient is demonstrating ing, strategies to compensate for impairments, suffi cient skill, he or she may be given homework and group discussion have shown some promise. to practice with people outside the class. The Reviews of cognitive remediation in schizophre- fi nal, and perhaps most diffi cult, step is to assist nia have suggested that the method produces the patient in generalizing improvements in social modest benefi ts on cognition but has little or no skills into everyday, real-life settings (Liberman impact on functioning (Krabbendam and Aleman 2008) . It is the doubts about whether this process 2003 ; Pilling et al. 2002 ) . A recent meta-analysis of generalization can be accomplished success- concludes, however, that cognitive remediation fully, that has put a damper on the diffusion of the produces moderate improvements in cognitive approach more broadly. A meta-analysis of stud- performance and functioning and that the impact ies of social skills training published in 1996, 19 Psychiatric Rehabilitation Methods 229 revealed that although the approach was effective provide three basic ingredients: (1) detailed in teaching patients interpersonal and assertive- information about the illness for the family and ness skills, few studies have examined whether patient, (2) help for the family to develop prob- training in the hospital setting generalizes to lem-solving mechanisms, and (3) practical and social interactions in the community (Dilk and emotional support (Leff and Vaughn 1985 ; Bond 1996 ) . For whatever reason, adoption of Falloon et al. 1982; McFarlane 2002 ; Leff 1996 ) . the model has not been strong and Liberman him- Family psychoeducational approaches have self reports that “its use is still limited to a rela- all proven highly effective in reducing the rate of tively small number of behaviorally oriented relapse in schizophrenia. The approach, however, practitioners” (Liberman 2008 ) (p. 271). has not disseminated at all broadly in community psychiatric practice anywhere in the world. Only 7% or fewer people with schizophrenia in the Working with Families USA, for example, get involved in a family inter- vention program (Lehman and Steinwachs 1998 ) . Behavioral Family Management There are a number of explanations for this. In many areas, few people with schizophrenia live Behavioral family management or the psychoed- with family. In addition, organized attempts to ucational approach to working with families of disseminate the model to mental health managers people with serious mental illness is covered in and providers have been almost nonexistent detail in Chap. 28. The approach is based on the because, unlike psychopharmaceutical products, robust results of research conducted in several no one stands to make a profi t from marketing the countries in the developed and developing worlds. approach, and those who could benefi t most, This research reveals that people with schizo- organizations of families of people with serious phrenia living with relatives (by birth or mar- mental illness, have often considered any form of riage) who are critical or overinvolved (referred family intervention to be stigmatizing and have to in the research as high “expressed emotion” or not lobbied for dissemination of the model. EE) have a much higher relapse rate than those Recently, however, the National Alliance on living with relatives who are less critical or intru- Mental Illness in the USA has launched a Family- sive (Leff and Vaughn 1985 ; Parker and Hadzi- to-Family education program on mental illness Pavlovic 1990 ) . Some studies have shown that taught by trained family members which has been relatives who are less critical and overinvolved shown to be effective in enhancing coping and exert a positive therapeutic effect on the person empowerment of families (Dixon et al. 2011 ) . with schizophrenia, their presence leading to a Most of the work cited above was published in reduction in the patient’s level of arousal (Tarrier the 1980s or early 1990s, and little development et al. 1979; Sturgeon et al. 1984 ) . There is no of the model has occurred in the past 15 years. indication that the more critical and overinvolved However, the advent of the internet has opened relatives are abnormal by everyday standards. It the door to new possibilities for disseminating is more likely, in fact, that the families in which the model. Recent publications describe a Web- people with schizophrenia do well have adapted based psychoeducational intervention for people to having a person with a psychotic illness in the with schizophrenia and their families (Rotondi household by becoming unusually low-key and et al. 2005, 2010 ) . The approach offers a secure permissive (Cheek 1965 ; Angermeyer 1983 ) . internet forum for family members and consum- Several studies have shown that family psy- ers led and moderated by trained facilitators and choeducational interventions can lead to a change an online library of educational resources. A ran- in the level of criticism and overinvolvement domized controlled trial of the approach led to a among relatives of people with schizophrenia and large reduction in positive symptoms in the con- a reduction in the relapse rate (Berkowitz et al. sumers and a growth in knowledge about schizo- 1981 ; Falloon et al. 1982 ) . Effective interventions phrenia in both patients and family members 230 R. Warner

(Rotondi et al. 2010 ) . Online delivery of family planners often seek to place people with psychiat- psychoeducation may have a promising future. ric disabilities in dispersed housing. They hope that by dispersing people in the broad commu- nity, community members will provide some of The Confi dentiality Barrier the needed support. This rarely happens, how- ever, and the people with mental illness often There is a simple approach which would have a have to turn to mental health professionals for big impact on the involvement of families in support. For some, the more direct route to social treatment—talk to them. Too often family mem- inclusion and successful community living may bers discover that they cannot get basic informa- be through enclave communities of people with tion about their relative when they call the hospital the shared experience of mental illness. or clinic. They are told that the information is A program in Santa Clara County, California, confi dential and protected by statute. Common explored this notion in the 1980s and 1990s sense and common courtesy, at the least, should (Mandiberg 1995 ) . Instead of dispersed housing, tell us that every patient, upon admission, should clients’ apartments were located so that no one be asked if he or she would like to sign a release of was more than 5 min walking distance from the information form allowing staff to communicate other residents—neither dispersed nor overly with speci fi c family members. This is rarely done clustered. In the geographic center of the hous- in US hospitals and clinics. Even without a signed ing, a space was rented for community activities. permission to release information, communica- Instead of residential supervisors, staff were hired tion is possible. As Robert Liberman writes: as community organizers and told that their task was to help foster a mutually supportive commu- Too many practitioners pay obeisance to a mis- guided conception of privacy and con fi dentiality. nity. The success of the Santa Clara County clus- There is no violation of con fi dentiality when a clini- tered apartment approach reminds us that the cian solicits information from family members. Can mutual support available in client communities anyone picture an internist or surgeon failing to may be turned to advantage and should be con- invite a close family member to provide confi rming and converging information regarding the patient as sidered as an option in developing housing strate- a key element in diagnosis and choice of treatment? gies for people with serious mental illness. Relatives are lucky if they get in to see the profes- sional responsible for the patient’s treatment, much less hear of the patient’s diagnosis and prognosis. Plainly speaking, relatives are ignored by mental Summary health professionals (Liberman 2008 , p. 299). Values—both hidden and evident—shape our psychiatric rehabilitation models, and the recov- Housing Strategies ery movement provides a series of values which have been guiding this work. Recognition of the Integrated Versus Clustered Living importance of empowerment for consumers of psychiatric services heightens our interest in the Supported housing models are discussed at length clubhouse model and other cooperative programs. in Chap. 29. As in other areas of rehabilitation An emphasis placed on work rehabilitation can practice, housing models are infl uenced by val- move us from a day-treatment approach towards ues. One value-based issue which comes into play the supported employment model and, thus, in devising approaches to housing is the question change many other aspects of a rehabilitation ser- of whether it is better to utilize the mutual support vice. A value placed on mutual support among that exists in client communities or to pursue the clients vs. mainstreaming will direct us toward a more usual principle of “mainstreaming.” To clustered apartment program or increase our inter- avoid creating mental health “ghettoes,” service est in social fi rms over supported employment. 19 Psychiatric Rehabilitation Methods 231

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