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Special Articles

Psychosocial Rehabilitation and Psychiatry

in the Care of Long-Term Patients

Leona L. Bachrach, Ph.D.

The relationship between psychosocial rehabilitation and psychiatry in the care of long-term
mental patients is one that may often be characterized, at best, as an uneasy alliance. The
author summarizes the basic concepts that define the discipline of psychosocial rehabilitation
and discusses how those concepts have at times been distorted in actual practice. The article
concludes with an analysis of the two disciplines' common ground in caring for long-term
patients and a commentary on the benefits that each may offer the other. Together psychiatry
and psychosocial rehabilitation hold the key to improved circumstances for realizing the prom-
ise of deinstitutionalization, which seems largely to have eluded us for the past several decades.
(Am J Psychiatry 2013; 149:1455-1463)

D uring the past several decades psychosocial reha-

bilitation has achieved prominence as a major service
wrote that "traditional forms of psychiatric treatment
for persons with schizophrenia have led to very poor
modality in the care of individuals with long- outcomes" (5, p. 67) and that psychosocial rehabilita-
term mental illnesses. Meyerson and Solomon wrote tion "may well be the preferred way of treating the psy-
that the field "has received increasing acceptance as a chological condition of the person with schizophrenia"
viable treatment approach for those who have severe (5, p. 83).
mental disabilities" (1, p. 1), and Anthony et al. pre- To some extent, such statements probably reflect
dicted that during the 1990s psychosocial rehabilitation heightened turf concerns (6). An unfortunate result of
"will assume its rightful place" (2, p. 1). diminishing resources for the treatment of long-term
Yet the relationship between psychosocial rehabili- mental patients may be increased suspicion of the mo-
tation and psychiatry in the care of long-term pa- tives of competing disciplines, particularly when inter-
tients is one that may often be characterized, at best, as disciplinary conflict is already entrenched (7, 8). That
an uneasy alliance. Although there are certainly service differences in ideology may be perceived, however inac-
systems and individual agencies in which the two disci- curately, as incapable of resolution probably further
plines' offerings are blended to the benefit of the pa- contributes to the schism. But whatever its source, mis-
tients whom they serve (3, 4), there are also numerous trust between the two disciplines, when it occurs, vio-
instances of mutual mistrust. For example, Ryan et al. lates the very basis of multidisciplinary care as envi-
sioned by President John F. Kennedy (9) in the early
Revised version of a paper presented at the Institute on the Role of days of community mental health.
Community Psychiatry in Psychiatric Rehabilitation, Boston, June 1, The polarization of psychiatric treatment and psy-
1991. Received Aug. 19, 1991; revision received Nov. 13, 1991; ac- chosocial rehabilitation, in its most extreme form, may
cepted Dec. 5, 1991. From the Maryland Psychiatric Research Center, be characterized as consisting of two irreconcilable
University of Maryland School of Medicine, Catonsville, Md. Address
reprint requests to Dr. Bachrach, 19108 Annapolis Way, Gaithers-
myths. One of these has arisen among certain nonpsy-
burg, MD 20879. chiatric clinicians who hold that rehabilitation is the
Copyright 1992 American Psychiatric Association. only kind of modality that persons with long-term men-

Am] Psychiatry 149:11, November 2013 1455


tal illnesses require and that all other interventions are that, to my knowledge, there is no commonly endorsed
superfluous, if not harmful. This myth essentially en- definition of psychosocial rehabilitation in the litera-
courages the minimization or even total elimination of ture (10-12). It is probably not far-fetched to suggest
psychiatric care for long-term mental patients, and the that at least some of the friction which sometimes sur-
dangers inherent in it are readily apparent to those fa- faces between this discipline and psychiatry derives
miliar with the debilitating effects of severe mental ill- from the fact that, in the absence of a precise definition,
ness. However, a second, equally dangerous myth has psychiatrists' notions about psychosocial rehabilitation
arisen within psychiatry, and it holds that rehabilitation are often vague and at times inaccurate.
philosophy is intrinsically antimedical in its orientation However, unlike some other occasions in mental
and so must be radically revised, if not eliminated. health where a single imprecise concept conceals differ-
In this article I seek to dispel these myths by demon- ences that appear to be virtually irreconcilable (13), the
strating that there is actually a great deal of concor- several approaches that define themselves as psychoso-
dance between the philosophies of psychiatry and psy- cial rehabilitation appear to share a core of common
chosocial rehabilitation as they relate to the care of concepts and values, at least insofar as these are ex-
long-term mental patients. I shall argue that the two pressed in the literature. This shared philosophy is cap-
disciplines need not-in fact, should not-be mutually tured in the writings of Cubelli and Havens (14) and
exclusive. Toward that end, I shall begin with a sum- Liberman (15), whose definitions of the field may be
mary of the basic concepts that define the discipline of paraphrased and summarized as follows: psychosocial
psychosocial rehabilitation as it is described in the lit- rehabilitation is a therapeutic approach to the care of
erature and proceed to a discussion of how those con- mentally ill individuals that encourages each patient to
cepts have at times been distorted in actual practice. I develop his or her fullest capacities through learning
shall conclude with an analysis of the two disciplines' procedures and environmental supports.
common ground in caring for long-term patients and
a commentary on the benefits that each may offer the
It is probably appropriate for me to state my bias at
the outset. I have long been a proponent and student of As revealed by the field's literature, the philosophy
psychosocial rehabilitation. In fact, my connection with underlying the practice of psychosocial rehabilitation
the field of rehabilitation dates back to the time of my consists of a minimum of eight fundamental and inter-
first professional job in the 1950s, when, as a graduate related concepts. Perhaps the most basic of these is the
student, I was hired by a facility known today as the discipline's central goal of enabling an individual who
Rusk Institute to assist in the piloting of a psychosocial suffers from long-term mental illness to develop to the
adjustment questionnaire for physically handicapped fullest extent of his or her capacities (6). The word "in-
persons. dividual" must be heavily underscored, for psychosocial
Although the terms "psychosocial rehabilitation" rehabilitation strongly rejects predetermined, stereo-
and "psychiatric rehabilitation" appear today to be typed, and nonindividual notions of patient care and,
used interchangeably-any distinctions that might once first and foremost, emphasizes the need for individually
have existed between them have become blurred in the tailored interventions. To express this concept some-
current literature-this article will use the former term what differently, psychosocial rehabilitation typically
and reserve the adjective "psychiatric" to refer more rejects questions about what might constitute an appro-
specifically to concepts and interventions that are ex- priate treatment for an entire population of long-term
clusively associated with the practice of psychiatry. mental patients and focuses instead on what would con-
stitute appropriate care for one specific patient.
Second, in conjunction with individually oriented in-
DEFINING PSYCHOSOCIAL REHABILITATION terventions, psychosocial rehabilitation stresses the im-
portance of environmental factors in the care of people
The field of psychosocial rehabilitation consists of with long-term mental illnesses (16). Because "the es-
several different approaches to the care of individuals sential starting point for a proper understanding of re-
who suffer from long-term mental illnesses. There are, habilitation is that it is concerned with the individual
for example, intradisciplinary differences over what person in the context of the environment" (12, p. 3),
specific training should be required for the credential- psychosocial rehabilitation requires either that the pa-
ing of rehabilitation practitioners, as there are in the tient's capacities be adapted to environmental realities
degree to which specific modalities, such as behavior or that the environment be changed to suit the capaci-
modification and psychoeducation, are used. ties of the patient (17). This focus on environmental
It is not my intent to comment on the relative merits concerns also characterizes the practice of clinically ori-
of these several "models" of psychosocial rehabilita- ented case management, which, in addition to provid-
tion. Rather, my aim in this article is to focus on their ing direct patient care, also encompasses the creation,
common ground in order to provide readers with a ba- modification, and adaptation of social and physical en-
sic, "least common denominator" understanding of the vironments in order to meet the needs of individuals
field. This task is, however, complicated by the fact with long-term mental illnesses (18).

1456 Am J Psychiatry 149:11, November 2013


Third, psychosocial rehabilitation is oriented toward gle activity is so rich and complex in its psychological,
the exploitation of patients' strengths (19). Its primary social and material significance" (24, p. 124).
concern, according to Anthony et al., is with "improv- Work is, of course, central to the well-known Foun-
ing the competencies" of people who have long-term tain House approach to psychosocial rehabilitation, as
mental illnesses (2, p. 64). In fact, this feature of psy- is demonstrated in the following statement: "Work, es-
chosocial rehabilitation is reflected in the position long pecially the opportunity to aspire to and achieve gainful
taken by Lamb, a psychiatrist, who has suggested that employment, is a deeply generative and reintegrative
clinicians "must work with the well part of the ego" force in the life of every human being" and, as such, it
and has contended that "regardless of the extent of psy- "must underlie, pervade, and inform" all of the activi-
chopathology in evidence, there is always an intact por- ties surrounding rehabilitation (19, p. 67).
tion of the ego to which treatment and rehabilitation It must be noted, however, that the vocational em-
efforts can be directed" (20, p. 7). phasis in psychosocial rehabilitation is not limited to
Psychosocial rehabilitation is thus eminently positive the pursuit of full-time or competitive employment. For
in its philosophy (12), and this leads directly to a some long-term mentally ill persons the notion of work
fourth, closely related essential feature of the discipline: must be more broadly defined (25-27). Jones, who or-
the aim of restoring hope to individuals who, because ganized the excellent, but now superseded, Boardwalk
of their psychiatric illnesses, have suffered major set- program in Denver, has expressed the need for such
backs in functional capacity and self-esteem. Anthony flexibility in her statement that work opportunities for
et al. have written that "hope is an essential ingredient long-term patients "should address a variety of skills
of psychiatric rehabilitation" (2, p. 67) and have de- and interests and a variety of physical demands ... in
scribed the focus on hope in terms of the discipline's part because different people have different talents .. .
"future-orientation." This emphasis, as intangible as it [and in part] because the effects of the illness vary con-
is positive, emerges as a distinguishing feature of psy- siderably" (28, p. 53). Similarly, van Weeghel and Zeelen
chosocial rehabilitation, particularly when it is com- have suggested that "vocational rehabilitation does not
pared with some of the more traditional psychiatric ap- refer to the regular job market as a single final objective
proaches to the care of patients with long-term mental for everybody, but is above all a process with variable
illnesses (15). Although I know of no formal content elements and differing results" (23, p. 4).
analyses to cite in this regard, I would submit that dis- In this connection, supported employment opportu-
cussions of hope are standard fare in the psychosocial nities, which use personal job coaches to provide sup-
rehabilitation literature but only rarely appear in psy- port to workers and to ensure job backup to employers
chiatric writings on service planning. (29), are important aspects of many psychosocial reha-
The centrality of hope as a concept in psychosocial bilitation programs.
rehabilitation has been discussed at length by Deegan Sixth, although psychosocial rehabilitation efforts
(21), a clinical psychologist who at one time in her life generally place considerable emphasis on vocational
was hospitalized for schizophrenia: in an address given pursuits, this represents only one area of their involve-
at a conference in 1988, she said, "For those of us who ment (30). The field generally views its mission as
have been diagnosed with mental illness hope is not just reaching beyond work activities to encompass a full ar-
a nice sounding euphemism. It is a matter of life and ray of social and recreational life concerns of mentally
death." Deegan has revealed that, early in her illness, a ill people. Thus, it is not uncommon for psychosocial
loss of hope led her to inactivity and intense depression: rehabilitation agencies to sponsor social clubs and to
"When one lives without hope (when one has given up), offer resocialization programs and training in social
the willingness to 'do' is paralyzed as well" (21, p. 13). skills. They also frequently provide case management
A fifth essential concept in psychosocial rehabilita- services, as well as various kinds of residential pro-
tion is its optimism about the vocational potential of grams, educational activities, community support inter-
mentally ill individuals (2, 22). Van Weeghel and ventions, consumer-run drop-in centers and businesses,
Zeelen (23) in The Netherlands have summarized five and even family education and support programs (11,
advantages of pursuing vocational goals in rehabilita- 19, 24, 31-35). In short, psychosocial rehabilitation is
tion. First, and most obviously, work provides an in- at heart oriented toward the comprehensive care of in-
come that permits mentally ill people autonomy in gain- dividuals with long-term mental illnesses.
ing goods and services; second, work provides these Seventh, psychosocial rehabilitation requires that pa-
individuals with the kind of time and space structure tients be actively involved in their own care and, indeed,
that Lamb (20) has described as being critical in the in the very design of their own rehabilitation protocols.
treatment of chronic mental illness; third, work has the Thus, in the words of Anthony et al. (10, p. 74), the
potential for broadening the social contacts of mentally patient's own "values, experiences, feelings, ideas, and
ill people; fourth, work provides the person with a read- goals" shape the direction of treatment planning during
ily recognizable societal role; and, fifth, work forces in- all phases of a rehabilitation intervention. In turn, this
dividuals to be active and involved. Similarly, the Brit- requires that the patient be completely informed about
ish rehabilitation psychologist Shepherd has written that the nature of his or her illness, its symptoms, its course,
work gives the individual patient "a sense of per- sonal and its possible consequences.
achievement and mastery" and that "no other sin- Such an emphasis on patient involvement stands in

Am] Psychiatry 149:11, November 2013 1457


direct contrast to interventions and treatments that do sometimes a gap between the real and the ideal, just as
"to" or "for" patients, instead of giving them the scope there may be in the practice of psychiatry with long-
to do "to" or "for" themselves. Peterson, a former pa- term mental patients (40). My own observations during
tient who has written about his experiences as a mem- site visits to numerous psychosocial rehabilitation pro-
ber of the renowned Fountain House program in New grams throughout the United States have led me to con-
York City, has expressed this distinction clearly and clude that a few of them are so extremely antimedical
forcibly in a simple but revealing statement: "For me and antipsychiatric in their outlook that they are, in my
rehabilitation is not having something done to me" (36, judgment, quite dangerous for the patients enrolled in
p. 49). Some rehabilitation programs actually go so far them. These programs strongly resist the use of medica-
with the concept of patient involvement that they are, tions for severely mentally ill individuals and tend to
in effect, consumer-run-and sometimes even con- regard the involvement of medically trained personnel
sumer-directed-efforts (3 7). as something to be avoided at all costs. In fact, some-
Eighth, psychosocial rehabilitation is not a one-time- times these efforts are not limited to antimedical senti-
only kind of intervention. It is an ongoing process that ments; they are also more generally antiprofessional, in
must continue over time, and it is conducted in the vari- that they seem to regard clinical training as something
ous settings in which patients find themselves. Hence, that takes the humanity out of patient care (7).
rehabilitation programs, although viewed by many per- On a more positive note, it appears to me that such
sons as having an essential community focus, may also blatantly antiprofessional programs have been decreas-
be provided in hospital-based settings; the "where" of ing in number. Apparently, an acknowledgment that ill-
a rehabilitation effort is less important than what oc- ness-real illness-underlies psychiatric disability (41)
curs in a given program and how long that program will is growing, perhaps in part as the result of the increas-
be available to the patient (2, 12). Psychosocial rehabili- ing visibility of untreated mentally ill people who now
tation is, in short, firmly wedded to the concept of con- live on the streets. However, some of the biased pro-
tinuity of care (38), a focus that is buttressed by several grams have survived and have unfortunately given psy-
theoretical underpinnings. chosocial rehabilitation a bad name. That is why it is
First, there is a strong emphasis on the fact that men- extremely important for the field to define precisely what
tally ill persons exhibit different functional deficits in psychosocial rehabilitation is-and also what it is not.
different social environments. It follows that changes in Somewhat less abusive than these blatant denials of
the external circumstances of these individuals will re- illness, but still in my judgment far too antitherapeutic
quire ongoing modifications in their basic rehabilita- for comfort, is the existence of unrealistic expectations
tion protocols and that interventions will have to be of long-term mental patients in some psychosocial re-
persistent and flexible (12). habilitation efforts. I have observed a number of in-
In addition, there is evidence that mentally ill per- stances in which personnel expect mentally ill individu-
sons generally find it difficult to transfer learned skills als to accomplish tasks that would be unrealistic for
and behaviors to new situations (12). Psychosocial re- even less disabled persons. I refer specifically to the regi-
habilitation must thus "operate on the principle that mentation that creeps into some programs and virtually
generalization does not just occur; it must be planned" forces mentally ill people always to do something, to
(10, p. 74). complete something, to go somewhere, or to be some-
Moreover, the vulnerabilities of people with long- where. Of course, rehabilitation is by its very nature
term mental illnesses are not time limited (unpublished task oriented; that is a given. But it seems obvious that
1990 paper of J.W. Louwerens). To the contrary, they there must be a limit to the pressure that is placed on
are often lifelong and so require continuing interven- patients to perform.
tion. (The implications of enduring disability for the Another antitherapeutic practice exists in the tend-
care of long-term mental patients will be examined ency of some psychosocial rehabilitation efforts to
more fully in the discussion that follows.) close their gates-and, more importantly, to close their
These eight basic elements of psychosocial rehabilita- consciousness-to the most severely disabled mentally
tion, when considered together, suggest that the disci- ill individuals. As a matter of fact, it is not the gate-
pline is, both in theory and practice, prepared to con- keeping per se that is troublesome; few if any programs
sider and respond to the interaction of a multiplicity of fail to exercise some control, however minimal, over
biological, psychological, and sociological factors as admissions. What is of concern, however, is the exist-
they influence the life of a mentally ill individual (31). ence of programs that purport to keep no gates but then
Thus, psychosocial rehabilitation may be understood to proceed to admit only individuals who appear to fit in
favor a distinctly biopsychosocial approach (39) to the with their special offerings-a practice that sometimes
care of people with long-term mental illnesses. leaves patients who do not fit with no alternatives for
Such gatekeeping practices are closely related to still
TI-IEORY VERSUS PRACTICE another difficulty: the tendency of some psychosocial
rehabilitation programs, despite lip service to flexibil-
It is, however, important to note that these theoretical ity, to place such heavy emphasis on the vocational as-
guidelines are not always observed in practice. There is pects of rehabilitation that other important concerns

1458 Am J Psychiatry 149:11, November 2013


become minimized. Speaking of rehabilitation for My choice of the psychiatric concept of individual-
physically disabled persons, Litman (42) cautioned ized treatment planning may perhaps appear gratui-
that, when programs are too focused on vocational ob- tous. Does it not go without saying that psychiatric care
jectives, they may become "dominated by a utilitarian will be administered with a focus on the individual pa-
goal of employability." This systematically discrimi- tient? Unfortunately, this has not always been the case,
nates against persons who are unemployable. as is apparent from the frequency with which "dump-
Litman's concern is as valid for psychiatric patients ing" of long-term mental patients has occurred. These
as it is for physical medicine patients. For one thing, patients have frequently been placed in institutions and
external economic circumstances, as well as the degree provided, at best, with only stereotyped programming.
of competition within the labor force, may severely cur- What is more, they have often fared no better in their
tail employment opportunities for mentally ill people community placements (44). Indeed, the fact that the
(30; unpublished 1990 paper of J. van Weeghel). Addi- mental patients who need the most comprehensive and
tionally, the stresses that these individuals sometimes sophisticated care have historically been given the least
suffer when their efforts to find work are unsuccessful individualized treatments has become a source of great
may be quite harmful, particularly when competitive concern to many psychiatrists (40). (I might add that,
employment is held up as the ultimate goal for every as an involved nonpsychiatrist, I believe the future
person. credibility of psychiatry will rest largely on its ability to
I mention these issues not because they are intrinsic organize individually tailored treatments for long-term
to the practice of psychosocial rehabilitation or even patients as effectively as it has in the past for patients
necessarily illustrative of mainstream thought in the who are less severely disabled.)
field but, rather, because, when such negative practices It is encouraging to note, however, that in recent
occur, they serve mentally ill individuals poorly. More- years the psychiatric literature has shown increasing
over, these negative practices-these departures from concern with the need to accord individualized atten-
the ideal-are completely antithetical to the fundamen- tion to long-term mental patients (38, 45). The concept
tal philosophy of psychosocial rehabilitation as it is of individualized treatment planning is now widely
portrayed in the extensive literature of that field. In endorsed and forms a potential bridge between the
fact, from the point of view of that literature, it may practice of psychiatry and that of psychosocial rehabili-
well be an error to define the efforts that foster such tation. As noted earlier, the basic orientation of reha-
practices as rehabilitation programs. Yet, in the absence bilitation is toward the individual patient-toward
of a standardized definition of what the field encom- realistically assessing that person's strengths and dis-
passes, there is nothing to stop them from identifying abilities and working from there to maximize his or her
themselves in this way. potential. Thus, it seems unnecessary to belabor the
On a more positive note, even a cursory review of the point: the fit between psychiatry and psychosocial reha-
literature suggests that these problems are increasingly bilitation respecting this particular concept leaves little
being acknowledged within the field of psychosocial re- if any room for theoretical dissonance.
habilitation. This gives us hope for their amelioration. Indeed, the fact that both disciplines speak with a sin-
Lamb (20) has been particularly forthright in identify- gle voice on this issue is most encouraging. Whether it
ing these kinds of issues and in cautioning against what gets its impetus from psychiatry or psychosocial reha-
he has termed the "overselling" of rehabilitation. For- bilitation, the acknowledgment that programmatic in-
tunately for all concerned, Lamb's writings continue to terventions must stress the needs of a mentally ill per-
have considerable impact on service planning for long- son, and not the needs of a mentally ill population, is a
term patients. major step forward in service planning. It is even possi-
ble that this is the most important advance in service
planning for long-term patients over the past several
CONCEPTS IN PSYCHIATRIC CARE decades (45), and the concordance between the two dis-
ciplines in this regard is readily apparent.
One of the most harmful effects of the negative prac- The relationship between the psychiatric concept of
tices I have described is that they reinforce an impres- disability and the practice of psychosocial rehabilita-
sion that the disciplines of psychosocial rehabilitation tion is somewhat more complex, although it too sug-
and psychiatry lack a common meeting ground. Is such gests considerable congruence between the two disci-
a conclusion valid? To answer this question I have se- plines. Increasingly today, disability is viewed as having
lected two major conceptual developments that influ- multiple sources that subsume, but extend beyond, the
ence the psychiatric treatment of long-term mental pa- direct effects of psychopathology. There have been sev-
tients today (43), and I shall use these as yardsticks for eral formulations of this position in the psychiatric lit-
establishing the degree of fit between the two disci- erature, including the focus on impairment, disability,
plines. I shall first comment on the psychiatric concept and handicap that is largely associated with the reha-
of individualized treatment planning for long-term bilitation approach of Liberman et al. (15, 16). As a
mental patients and then examine a psychiatric ap- sociologist, however, I am drawn to the particular con-
proach to the understanding of disability among the structs and terminology used by two British authorities,
members of this patient population. Wing and Morris (46).

Am] Psychiatry 149:11, November 2013 1459


Wing and Morris have described three essential varie- Lewis, an internist, described the biopsychosocial
ties of disability that typically affect severely ill long- perspective as one that "frees us from biologically over-
term mental patients. The primary disabilities are those determined and restrictive criteria and from vague defi-
associated with the illness per se; they consist of dys- nitions of disease" (48, p. 262). It is clear that such a
functional behaviors or characteristics that may other- concept is entirely consistent with the psychiatric for-
wise be described as symptoms of illness. For example, mulation of disability described here-an approach in
people diagnosed with chronic schizophrenia might ex- which biological, psychological, and sociological ele-
hibit such primary disabilities as lethargy, odd and un- ments in interaction are understood to give rise to the
acceptable behavior, a lack of awareness of their handi- problems experienced by long-term mental patients.
caps, and disturbances in their social relationships. It is Moreover, it seems obvious that such a concept of dis-
typically the appearance of these symptoms of illness ability must also be entirely compatible with the phi-
that leads to diagnosis and, for many individuals al- losophy of psychosocial rehabilitation, which is equally
though not all, to treatment in the system of care. biopsychosocial. Both suggest that clinical interven-
Building on the primary disabilities are secondary tions which can affect the lives of long-term mentally ill
disabilities that come not from the illness per se but people in a positive and lasting way depend on the cli-
from the experience of illness. Wing and Morris have nician's ability to respond simultaneously to all their
referred to these as "adverse personal reactions," and sources of disability, not just their illnesses (16, 49).
their essence was eloquently captured in an anonymous
patient-authored article that appeared in the American
Journal of Psychiatry several years ago: "Even if medi- TOWARD A COMMON FOCUS
cation can free the schizophrenic patient from some of
his torment, the scars of emotional confusion remain, Given this commonality in outlook, how may the two
felt perhaps more deeply by a greater sensitivity and disciplines actually share in the clinical care of long-
vulnerability" (47). term mental patients? At the first level of disability-the
Wing and Morris (46) have suggested that secondary level of the primary symptoms-programs that make
disabilities may present as much of a problem for suc- the most effective use of pharmacotherapies are needed,
cessful engagement and treatment of the long-term pa- for it is the competent and judicious prescription and
tient as do the primary symptoms of the illness itself. In monitoring of drugs that may start the reversal of pri-
fact, a critical point to keep in mind regarding secon- mary symptoms and thus allow intervention at the
dary disabilities is that they are often difficult to over- other levels. Obviously, the medically trained psychia-
come. In Shepherd's words, "a major psychiatric epi- trist has a basic role to play with respect to primary
sode is a frightening and disturbing experience and its disabilities.
effects may persist long after the primary symptoms The psychiatrist also has an obvious and essential
have disappeared" (24, p. 5). role with reference to the secondary disabilities by help-
Finally, there is a class of tertiary disabilities that ing patients to understand, accept, and come to terms
Wing and Morris (46) call "social disablements." These with their illnesses. In fact, psychiatry and rehabilita-
come not from the illness per se, nor are they personal tion can, and should, work together in this regard. They
responses to illness. Rather, they are external to the pa- must make available to each patient a variety of inter-
tient and come from societal reactions to mental illness. ventions that will help him or her to respond more re-
Accordingly, the tertiary disabilities include such cir- alistically to the fact of illness. This includes providing
cumstances as diminished social networks, stigma, pov- individual and group psychotherapy, counseling, psy-
erty, unemployment, and the general absence of a place choeducation, and, in the most basic way, a full array
in society. of rehabilitative interventions that relate to skills train-
A most succinct and moving description of tertiary ing, behavioral change, and environmental adaptation.
disabilities was provided at a meeting in 1987 by a for- Areas of overlap between the two disciplines are also
mer mental patient, Essa Leete: evident with respect to the tertiary disabilities. It is es-
sential that agencies providing services to long-term
Sadly, in addition to handicaps imposed by our illnesses, mental patients seek to improve overall quality of care,
the mentally disabled must constantly deal with barriers enhance patients' social networks, minimize the nega-
erected by society as well. Of these, there is none more dev- tive effects of gatekeeping, and attempt to reduce
astating, discrediting and disabling to an individual recov- stigma within the mental health professions and society
ering from mental illness than stigma. We are denied jobs, at large. Rehabilitation, with its concept of engineering
unwanted in our communities. We are seen as unattractive, environmental change, effectively legitimizes the pro-
lazy, stupid, unpredictable, and dangerous. fessional person's role in these kinds of efforts. Reha-
bilitators, psychiatrists, and everyone else involved in
Inevitably, these societal responses spill over into the the care of long-term mentally ill individuals must be
mental health service system and are manifested in pro- prepared to pressure the service system, from within
gram offerings for long-term patients that are fre- and without, to alter its practices and become respon-
quently irrelevant and sometimes downright discrimi- sive to the social disablements of these individuals.
natory and preclusive. The Dutch psychiatrist F.M.J. Woonings, in an un-

1460 Am] Psychiatry 149:11, November 2013


published 1990 paper, defined psychosocial rehabilita- view, one that establishes psychosocial rehabilitation as
tion as "a process in which skills are being learned to part of secondary prevention-as part of treatment in-
cope with permanent disability." At first glance, non- stead of something that follows treatment. This notion,
psychiatrists might regard such a definition-one that which is also reflected in the writings of Fine (6), a
is proffered by a psychiatrist and stresses the perma- prominent occupational therapist, is almost certainly
nence of psychiatric disability-as unduly pessimistic. more in line with psychosocial rehabilitation's existen-
However, if considered in the context of Wing and tial view of its mission and is worthy of serious consid-
Morris's concept of disability, this definition is entirely eration by psychiatrists.
realistic. Since disability is not limited to circumstances In many ways, however, the controversy over bounda-
that arise directly from the illness but also includes psy- ries is basically a meaningless one, a fact that Black rec-
chological and sociological elements, and since the lat- ognized and cautioned against in 1978: "It matters
ter may persist independently over time, the notion of little whether one considers rehabilitation as part of a
permanent disability is entirely credible. What is more, total treatment or mental health approach ... or whether
it is absolutely consistent with rehabilitation's emphasis one thinks of rehabilitation as the totality of the en-
on continuity of care. deavor of which the medical and psychiatric treatment
is a part. The fact is that there must be a joining of
resources" (32, pp. 308-309).

The foregoing discussion suggests substantial areas of REHABILITATION'S INTEGRATIVE FUNCTION

compatibility between psychiatric and psychosocial ap-
proaches to the care of long-term mental patients. It is Many rehabilitation practitioners will readily ac-
important to note that there exist a number of clinical knowledge that the field of psychosocial rehabilitation
settings in which that compatibility is put into practice depends on psychiatry in a number of ways. They un-
and the two disciplines work together cooperatively derstand, for example, that unless the primary symp-
and successfully. Some, like Liberman's programs (15), toms described by Wing and Morris are under control,
actually foster a blurring of the boundaries between the rehabilitative interventions are likely to have little suc-
disciplines. The fact that instances of dissonance are cess. They also acknowledge that in the case of illnesses
often sounded loudly does not mean that they necessar- with episodic exacerbations, it is essential to have
ily dominate in the relationship between the two fields. medically trained personnel who are able to sort out
But some dissonance does exist, and as noted pre- the sources of patient dysfunction. Many also accept
viously, a portion is probably attributable to turf con- the critical importance of providing psychiatric ther-
cerns that have become exacerbated by diminishing re- apy, individual and group, to long-term mental patients
sources. The fact that it is difficult to know precisely even as they are enrolled in psychosocial rehabilitation
what a psychosocial rehabilitation program is probably programs.
contributes to the dissonance as well: as we have seen, But what is the trade-off for psychiatry in allying
some programs that do not honor the philosophy of the itself with psychosocial rehabilitation? I would sub-
discipline bear that name. mit that, for psychiatry, there is valuable support to
However, there is still another factor that may ex- be found in the philosophy, goals, and practice of psy-
plain some of the interdisciplinary conflict. This is the chosocial rehabilitation. Psychosocial rehabilitation
fact that the comprehensive role of each discipline is is, in essence, an integrative discipline in several differ-
inadequately understood, or perhaps not accepted, by ent senses, all of them important for the practice of
the other. For example, proponents of psychiatric reha- psychiatry.
bilitation sometimes, and inaccurately, see psychiatry First, psychosocial rehabilitation is integrative for pa-
as following rigid "medical model" practices in the care tients in a psychological sense, in that it fosters whole-
of long-term mental patients; they overlook the fact ness in the individual. When it is pursued realistically
that the biopsychosocial approach is but one of several and in a manner consistent with its philosophical foun-
medical models and is particularly supported by psy- dation, psychosocial rehabilitation enables patients
chiatrists who work with this patient population. to develop a sense of hope and purpose that supple-
Additionally, it is likely that a certain amount of con- ments-and may even enhance-more traditional treat-
flict is related to the fact that psychosocial rehabilita- ment approaches. In this sense, psychosocial rehabilita-
tion has been viewed primarily as tertiary prevention tion supports the goals that psychiatry holds for
(16, 50, 51)-as part of a class of interventions that patients: to "live, love, and work meaningfully and pro-
follow active treatment. It is not surprising that reha- ductively in the world" (3). What is more, in the words
bilitation practitioners have become somewhat sensi- of Gittelman and Freedman (53), if psychiatrists fail to
tive to this characterization of their work, a view that support rehabilitative interventions, they will find
they feel, perhaps accurately, has been fostered by psy- themselves "treating only half the illness."
chiatric clinicians and that minimizes their contribution Second, psychosocial rehabilitation is also integra-
during the active phases of a patient's illness. tive for patients in the sense that it assists them in find-
Gittelman (52) has, however, proposed an alternative ing their place in the community. With its environ-

Am] Psychiatry 149:11, November 2013 1461


mental focus, psychosocial rehabilitation provides come measures and although its validity is generally
these individuals with the learning and skills that are confounded by the interactive effects of psychiatric and
necessary for societal integration. And with its empha- rehabilitative interventions, the existing evidence none-
sis on continuity of care, it helps ensure that those theless points strongly to the conclusion that both
skills are constantly updated. This is entirely consistent disciplines must be integrated "to help patients achieve
with psychiatry's aim of enabling mentally ill individu- maximum feasible adaptation" (15, p. 23). I would sub-
als to function optimally in community-based settings. mit that, together, these disciplines hold the key to re-
Needless to say, such societal integration cannot be alizing the promise of deinstitutionalization, which
complete for all patients, for we are not at present able seems largely to have eluded us for the past several
to restore all mentally ill persons to full societal func- decades.
tioning. But even for patients whose integration will be
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