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, re fi 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 con fi 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 bene fi 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 scienti fi 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 in fl 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