In Review

Rehabilitation in the United Kingdom: Research, Policy, and

Practice
Frank Holloway, MA, MB, FRCPsych1, Jerome Carson, BSc, MSc2, Sarah Davis, DipOT3

Objective: To review research, policy, and practice in psychiatric rehabilitation in the UK.
Method: We undertook a literature review and review of government policy documents.
Findings: Most individuals with severe, disabling mental illnesses are cared for by generic
community mental health services under the Care Programme Approach (CPA). Current gov-
ernment policy requires the introduction of assertive outreach and early psychosis services and
is highly consistent with the adoption of the recovery paradigm within UK mental health serv-
ices. Research and development activities have demonstrated the success of the UK hospital-
closure program and have contributed to the worldwide resurgence of interest in psychosocial
interventions in psychosis.
Conclusions: A need remains to focus research and practice on those who are most disabled
by their illnesses and to improve the skills of the workforce in psychosocial interventions.
(Can J Psychiatry 2002;47:628–634)
See page 634 for author affiliations.

Clinical Implications
· Mental hospital closure can be carried out with good outcomes for long-stay patients.
· The Care Programme Approach (CPA) requires community follow-up of people with severe
mental illness.
· Effective psychosocial interventions for schizophrenia have been developed.

Limitations
· The configuration of UK rehabilitation services is ill-defined.
· Little evidence exists with respect to the outcomes of rehabilitation services.
· Evidence for the implementation of psychosocial interventions in routine clinical practice is
limited.

Key Words: rehabilitation, recovery, Care Programme Approach, psychosocial interven-

tions
his paper reviews the current status of psychiatric reha-
T bilitation in the UK. The term is not fashionable; in fact,
the word “rehabilitation” rarely appears in UK mental health
policy documents. The first and last major UK textbook on the
topic was published almost 2 decades ago (1). Despite a long-
standing policy focus on severe mental illness and the large
proportion of mental health spending allocated to long-term
care, few UK mental health professionals specialize in reha-
bilitation. A survey undertaken by the Royal College of Psy-
chiatrists identified only 46 consultant psychiatrists working
full-time in rehabilitation in England in 2000 (that is, less than
one per million population). This current low profile reflects
the history of rehabilitation services (which flourished in the
traditional mental hospital), shows the continuing ambiguities
over the meaning of the term, and reveals a long-standing dif-
ficulty in acknowledging the realities of continuing disability
in an era of community mental health care.
Bennett (2) provided an overview of the development of psy-
chiatric rehabilitation services in the UK. Historically, these
services were based in the mental hospital. Rehabilitation

628
W Can J Psychiatry, Vol 47, No 7, September 2002
 Rehabilitation in the United Kingdom: Research, Policy, and Practice
aimed to enable individuals to move out of hospital, either
back to their home or to a supported care setting. Long-stay
patients moved down and then up a ladder, from the acute
ward to the back ward, on to the rehabilitation unit, and even-
tually out of hospital.
The second half of the 20th century saw a dramatic decline in
psychiatric bed numbers in England, from a peak of over
150 000 in 1954 to 38 000 in 2000 (from 330 per 100 000
population to 70 per 100 000). However, it was only in the late
1980s that the mental hospitals began to close. Rehabilitation
as a process of resettlement proved spectacularly successful:
approximately 100 of the 130 large English and Welsh mental
hospitals have closed in the past 15 years. Much of the repro-
vision within the hospital closure program was based on
Wolfensberger’s normalization or social role valorization the-
ory (3), an ideology that can be interpreted as denying the real-
ity of the severe psychiatric disabilities experienced by former
mental hospital patients. Denial of disability has been a recur-
rent theme in the era of community mental health care (4). The
hospital closure and reprovision programs that took place in
England during the late 1980s and 1990s were carefully evalu-
ated. However, less is known about the fate of the many thou-
sands who left the declining hospitals in the decades before
the closure program—anecdotally, often with only the price
of a railway ticket and the address of a boarding home in a sea-
side town.
Psychiatric rehabilitation, frequently defined as a set of spe-
cialist services, could be defined as an area that considers the
needs or characteristics of people who would benefit from re-
habilitation inputs. Wykes and Holloway defined the potential
client group as “people with severe and long-term mental ill-
nesses who have both active symptomatology and impaired
social functioning as a consequence of their mental illness”
(5). The development of specialist rehabilitation services is
very patchy and, following the hospital closure program,
there is also a much larger de facto system of continuing care
within generic mental health and social care services. Each lo-
cality has a substantial population of severely mentally ill peo-
ple receiving supportive care in what might be termed a
“virtual mental hospital.” This largely comprises an uncoordi-
nated network of private and voluntary sector residential pro-
vision, family care, and support from the generic community
mental health teams (CMHTs). These and their associated
acute inpatient units form the backbone of UK mental health
services. Services for forensic (offender) patients are pro-
vided at a regional level (medium-secure units) and within 4
high-secure hospitals. Some localities can arrange for special-
ist forensic community supervision and, in recognition of the
long-term nature of some patients’ needs, there is an emergent
specialty of forensic rehabilitation (6).
W Can J Psychiatry, Vol 47, No 7, September 2002
The UK rehabilitation tradition tends to concentrate on the
provision of a caring and supportive environment that maxi-
mizes the individual’s capacity to live as ordinary a life as pos-
sible, despite any residual disability (5). This is in contrast
with the US focus on rehabilitation readiness and the achieve-
ment of behavioural change, which would enable the person
to live without support (7). UK practitioners have always been
skeptical of the value of behaviourally based social skills
training for patients with schizophrenia (8), despite the opti-
mistic claims in the US literature (9). Even so, the UK tradi-
tion has sought to improve patients’ functional abilities
through occupational therapy and behaviour-oriented nursing
inputs, to the extent that they could live in the least restrictive
possible environment.
Recently, the rhetoric of recovery has begun to influence the
UK discourse on rehabilitation (5), partly in response to intel-
lectual trends emanating from the US and partly influenced by
the burgeoning indigenous UK user or survivor movement.
This paper describes recent trends in health and social care
policy. Further, it reviews research and practice relevant to the
treatment and support of people who are categorized into the
definition provided by Wykes and Holloway (5), most of
whom will fall outside any formal rehabilitation service.
Health and Social Care in the UK
The UK is a federation; health and social policy is in the hands
of its constituent Departments of Health. The same broad
service principles apply throughout the UK, although health
spending is significantly higher in Scotland, and the move to-
ward community mental health care has been slower in Wales,
Scotland, and Northern Ireland. Total UK health spending,
which is largely public rather than private (84% public), is
lower than in other advanced industrial nations (per capita
US$1418, compared with, for example, US$2102 in France
and US$3950 in the US) (10). A lesser proportion of gross do-
mestic product is spent on health in the UK (6.7%, 9.4%, and
13.0%, respectively, for the 3 countries).
Health care is free at the point of delivery, funded from taxa-
tion, provided by the National Health Service (NHS), and, in
principle, comprehensive. Access to specialist services, in-
cluding psychiatric care, is traditionally from general practi-
tioner referral. Individuals with a severe mental illness,
however, commonly enter specialist mental health services,
having bypassed the primary care filter (11). Health service
providers (“trusts”) have clear-cut geographical responsibili-
ties that are defined in contracts with their commissioners.
The precise organizational structure regularly changes, but
commissioners are essentially agents of the Department of
Health (DoH). Providers are currently agglomerating; in fact,
a number of mental health trusts are responsible for a catch-
ment area of 1 million people.
629
The Canadian Journal of Psychiatry—In Review
Access to social supports such as residential, day, and domi-
ciliary care is means-tested and provided through local
authority social services departments. These departments
contract out many services to a mixed economy of voluntary
and private sector providers. Local government receives
block grants from central government, with a local political
process that decides on spending. In addition, the Department
for Work and Pensions (DWP) disburses welfare benefits.
Newly formed, the DWP is responsible for programs that
bring people back into the workforce.
Approximately 11% of health spending is allotted to desig-
nated mental health services for all age groups, while 5% of
social service spending goes toward mental health. Although
health and social care policy for England is set and monitored
by the DoH, actions by the Treasury, the Home Office (re-
sponsible for the criminal justice system), the DWP, local
politicians, and local commissioners have a profound impact
on the welfare of people with severe mental illness. For exam-
ple, a lack of funding from DWP for employment programs,
combined with the regressive policies toward income from
employment by people with disabilities, makes reintegration
of individuals with severe and recurrent mental illness into the
workforce particularly difficult. This is despite a strong policy
emphasis on social inclusion.
There is a long-term continuity in the UK’s mental health pol-
icy that takes away from the institution and toward commu-
nity care. Nevertheless, since the early 1990s, a moral panic
over community care has resulted in policy being dominated
by concern over the risks people with mental illness present to
themselves and others (12). This has led to increasing empha-
sis on monitoring and coercing patients into treatment adher-
ence and over the past decade has been associated with a
marked trend toward more compulsory inpatient admissions.
Modernization
Since the election of the UK Labour Government in 1997,
health and social care has been near the top of the list of politi-
cal priorities and, consequently, has been the focus of inten-
sive policy development. The modernization agenda is set out
in a 10-year NHS Plan (13). This demands service reform in
return for promised investment that will bring UK health
spending up to the European Union average. One crucial ele-
ment of modernization is a new flexibility for local health and
social services to form integrated provider organizations that
are jointly commissioned by the NHS and the Local Author-
ity. Increasingly, mental health providers have health and so-
cial work staff working under joint management.
There is an ambitious health informatics strategy that envis-
ages developing an electronic patient record as well as the rou-
tine use of clinical outcome measures within mental health
(14). Practitioners are also encouraged to access good quality
630
information on services and treatments, including the Co-
chrane Collaboration Database, through several portals that
include a Centre for Evidence-Based Mental Health
(www.cebmh.com). The aim is to enhance evidence-based
health and social care practice. This sits within a broader strat-
egy for clinical governance that places quality at the heart of
services (15).
Service-specific national service frameworks (NSFs) and the
National Institute for Clinical Excellence (NICE) set stan-
dards for health service providers. NICE has produced guid-
ance on the use of antipsychotics, legitimating the use of
atypicals in first-onset patients and those with significant ex-
trapyramidal side effects (16). The Commission for Health
Improvement scrutinizes provider clinical governance ar-
rangements and pays particularly close attention to the user
and caregiver experience and to the integration of user and
caregiver views into service planning and provision (17). So-
cial care and independent sector health care providers are
monitored through the independent National Care Standards
Commission (visit www.carestandards.org.uk for a descrip-
tion of the NCSC). NHS commissioners and providers are
monitored through a National Performance Framework. Pro-
viders are rewarded (in terms of increased autonomy and fi-
nancing) and punished, depending on their performance.
Modernizing Mental Health Services
Modernizing Mental Health Services: Safe, Sound and Sup-
portive (18) provided a strategy for reform and change. It in-
cluded a commitment to reform mental health legislation. The
planned new Mental Health Act, jointly sponsored by the
DoH and the Home Office (19), is part of a wider public pro-
tection strategy. It ensures that individuals with a mental dis-
order can be treated compulsorily in the community, it
achieves compliance with the Human Rights Act (which in-
corporates the European Convention on Human Rights into
UK law), and it allows preventative detention of people with
dangerous severe personality disorder.
The NSF for Mental Health articulated broad service princi-
ples and standards for services (20). The standards cover
health promotion, primary mental health care, services to
caregivers, steps to reduce suicide, and standards specifically
focused on the needs of people with severe mental illness. A
Care Programme Approach (CPA), first introduced in 1991,
was relaunched in 1999 (21). A care plan that considers the
views of users and their caregivers must be in place for all peo-
ple in contact with specialist mental health services, and risk
assessments must be undertaken. People placed on enhanced
CPA, who have complex needs, are subject to regular multi-
disciplinary review and must be followed up, whatever their
wishes.
W Can J Psychiatry, Vol 47, No 7, September 2002
 Rehabilitation in the United Kingdom: Research, Policy, and Practice
The National Confidential Inquiry into suicides and homi-
cides by individuals with mental illness has produced 2 re-
ports that contain numerous recommendations aimed at
reducing suicide and homicide in the UK (22). Key recom-
mendations, which include rapid follow-up of all patients
leaving a psychiatric hospital and regular risk assessment
training for all staff, have become part of the performance
management framework for mental health services (23). De-
spite the moral panic that has driven this policy focus, homi-
cides carried out by individuals with a severe mental illness
have steadily declined as a proportion of total homicides in the
UK during the era of community care (24).
Policy Implementation Guide
The NHS Plan made specific commitments with respect to
change in mental health services. These were elaborated in a
Policy Implementation Guide (PIG) (25) and are based on the
functionally differentiated service model developed in North-
ern Birmingham. This sharply contrasts with the standard UK
model, based on a generic CMHT. “Health economies” (the
jargon term for stakeholders in health and social care within a
local area led by the commissioners) must develop 3 specialist
teams to complement the CMHT and any existing local spe-
cialist and rehabilitation provision. These teams include a cri-
sis resolution and home-treatment team (to decrease
admissions), an early-onset psychosis service (to manage new
presentations of psychotic illness in individuals aged 14 to 35
years), and an assertive outreach team (to provide treatment
and care for difficult-to-engage service users with a severe
mental illness).
The potential value of assertive outreach had previously been
identified in Keys to Engagement, a report from the Sainsbury
Centre for Mental Health (26). This influential nongovern-
mental organization promoted assertive outreach—a concept
derived from the pioneering work of Stein and Test (27)—as a
solution to concerns that some individuals with severe mental
illnesses were falling through the cracks of the mental health
system, despite the CPA. These services should be distin-
guished from existing rehabilitation outreach teams, which
tend to cater to an older, more functionally impaired client
group. Policy interest in first-onset services reflects, in part,
the influence of the pioneering early intervention service in
Northern Birmingham (28), while the crisis resolution strand
reflects concern to minimize use of psychiatric beds.
The PIG has subsequently been updated with further guidance
on other service areas, including the management of comorbid
substance misuse, psychiatric intensive care and low secure
services, and acute inpatient services. Like all Department of
Health papers, the PIG is available on the DoH Web site
(www.doh.gov.uk). In 1999, health economies were required
to set up local implementation teams (LITs). LITs are
W Can J Psychiatry, Vol 47, No 7, September 2002
responsible for putting the NSF and the mental health compo-
nents of the NHS Plan into practice. In 2002, LITs reported to
their performance managers the key items that were relevant
to people with a severe mental illness and consequent social
disability, such as progress in developing the PIG functional
teams and availability of secure hospital services. Joint pri-
mary and secondary care registers of individuals with a severe
mental illness are mandatory. The CPA documentation must
record the employment, occupational, and financial needs of
users on “enhanced” CPA, and services should be available to
meet these needs. Strategies for the management of people
with a dual diagnosis (that is, mental illness and substance
misuse) and for meeting the needs of caregivers are required.
Until very recently, UK research into employment and dual
diagnosis issues has not gone beyond mapping out the size of
the problem, and thus policymakers have been forced to look
to models derived from US literature.
The DoH has funded an ambitious service-mapping exercise
for England. The 2001 report is available on the Internet at
(http://www.dur.ac.uk/service.mapping). The data are incom-
plete but do demonstrate striking variability in both acute and
long-term care provision—including designated rehabilita-
tion teams, rehabilitation beds, and work provision—across
the country that cannot be explained by local demand. Over
time, these variances are likely to diminish.
Research and Severe Mental Illness
Hospital Closure
One of the recent triumphs of mental health services research
in the UK has been to document the process of closure of large
mental hospitals. The Team for the Assessment of Psychiatric
Services (TAPS) study into the closure of 2 London mental
hospitals (29,30), along with other more modest research pro-
grams carried out in the late 1980s and early 1990s, provided
reassuring evidence of the outcome of well-conducted mental
hospital closures. The uniform findings were that moving out
of the mental hospital into well-resourced nonhospital provi-
sion improved the life circumstances and social functioning of
the residual long-stay patients, most of whom had spent dec-
ades within the hospital and had failed within traditional reha-
bilitation services. However, and perhaps not surprisingly, the
resettlement process had little impact on psychiatric
symptomatology.
The New Long Stay
Less well-developed than the hospital-closure literature are
studies on the needs of people accumulating in psychiatric in-
patient beds in the era of determined community care, the so-
called “new long stay.” This is partly because, following the
demise of the UK psychiatric case registers in the late 1980s,
sampling frames to address service issues from an
631
The Canadian Journal of Psychiatry—In Review
epidemiological basis became difficult to establish. Despite
this, both national surveys (31) and more detailed local studies
(32), have identified a diagnostically heterogeneous group
with highly complex needs, characterized by behavioural dis-
turbances. As a result, this group is unacceptable to private
and voluntary nonhospital service providers. Behaviours that
predict continuing hospital care for new long-stay patients in-
clude absconding, noncompliance with treatment, bizarre be-
haviour, disturbance at night, and violence (32).
Even within highly deinstitutionalized services, a small but
significant group of individuals have been identified as those
requiring extensive periods of hospital-based care, often in
conditions of some security (32). Secure beds form the one
sector of psychiatric inpatient provision that has grown in the
past decade in England, with a burgeoning network of private
sector hospitals taking in patients for whom local services
cannot manage.
We have learned what makes for good and bad institutional
care (33,34). However, little empirical research has been done
in the past 2 decades about effective treatment practices
within long-stay hospital settings and their high-support com-
munity analogues. In addition, little research exists with re-
spect to the nursing and occupational therapy interventions
that constitute a major part of rehabilitation practice (35). The
TAPS study found that difficult-to-place patients who were
leaving Friern and Claybury Hospitals and who were younger
and had a shorter mean length of stay than did the bulk of the
long-stay population could be successfully cared for within
the well-staffed and highly structured community units in
which they were placed. There was significant reduction in
aggressive behaviours over time (36).
There is some evidence for the value of the hospital hostel or
ward-in-a-house approach (37,38), although the prototypes,
which were run on behavioural lines in London and Manches-
ter, have long since closed. Their successors offer 24-hour
nursing care in nurse-led community units, often run by the in-
dependent sector working in partnership with NHS providers.
Further, these units can offer an undoubted improvement on
the traditional mental hospital (39).
Community Support
The pioneering work of Stein and Test (27) into Assertive
Community Treatment (ACT) stimulated a worldwide re-
search effort into the provision of intensive community sup-
port for individuals with severe mental illness. The Maudsley
Hospital in London undertook one of the early and successful
replications— the Daily Living Programme (DLP) (40). Sub-
sequent UK studies that have tried to put ACT principles into
practice have been less positive (41–43). Critics have asserted
that these studies were inadequate replications of ACT
(44,45). Burns and others, who reviewed the European
632
literature, put forward an alternative argument (46). They con-
cluded that what works in one culture and health care system
at one time may be inapplicable elsewhere and at a later date,
when the services providing the control condition have moved
on.
Psychological Treatments for Psychosis
A rich research tradition into psychological treatments for
psychosis exists in the UK. It dates back to the pioneering
work of Brown and Rutter, who introduced the concept of ex-
pressed emotion in families of people with schizophrenia
(47). This work has led to important and positive studies into
family interventions using the expressed emotion paradigm
(48,49). Tarrier and colleagues found that a behavioural fam-
ily intervention was superior in terms of relapse in the short
term to a family-meeting condition and treatment as usual,
both in the short and long term (50). However, in common
with findings worldwide (51), family interventions in psycho-
sis are not part of mainstream services.
Several research teams in the UK have pioneered the use of
cognitive-behaviour therapy (CBT) in schizophrenia. Studies
have investigated the application of CBT to medication-
resistant outpatients (52–54) and to inpatients with acute psy-
chosis to as an adjunct to antipsychotic treatment (55). A tar-
geted intervention based on motivational interviewing
techniques to enhance the compliance or adherence of patients
with psychosis to medication has been evaluated (56).
An important conceptual and practical development, based on
pioneering work by Birchwood and others (57), is the identifi-
cation of individualized “relapse signatures,” encouraging the
patient and caregivers to monitor early signs of psychosis and
to develop a relapse plan (58). Relapse planning is incorpo-
rated into CPA guidance and routinely forms part of care plan-
ning under the CPA (21).
Wykes and others developed a promising additional psycho-
logical technique that targets the basic neurocognitive deficits
associated with schizophrenia (59). Their study compared
cognitive remediation therapy with an equally intensive con-
trol condition based on occupational therapy interventions
and subsequently found significant improvement on cognitive
measures. In general, the treatment programs that UK reha-
bilitation services offer take into account few of the cognitive
deficits of service users (5). Clinical psychology is a scarce re-
source, and cognitive assessment is not standard practice in
the UK.
Barrowclough and others reported positive findings from a
study of the value of a comprehensive package of psychoso-
cial interventions (combining family work, individual CBT,
and motivational interviewing) in the care of individuals with
comorbid substance misuse and schizophrenia (60). Few con-
temporary services in the UK would be in a position to provide
W Can J Psychiatry, Vol 47, No 7, September 2002
 Rehabilitation in the United Kingdom: Research, Policy, and Practice
such a package routinely, owing to an acute shortage of staff
trained in sophisticated psychological interventions.
Future Directions
Despite the lack of explicit acknowledgement of rehabilita-
tion, current policy does favour key rehabilitation principles.
An overarching desire exists to foster social inclusion of all
marginal groups, including people with a mental illness. The
CPA represents a uniquely ambitious attempt to ensure that all
users of psychiatric services (and their caregivers) receive a
holistic assessment that goes beyond immediate health care
needs. DoH publications embrace the rhetoric of recovery
(61), and there is a strong central trend to empower service us-
ers to participate in the planning and provision of services
(15,23).
Although central guidance continues to focus on primary care,
acute psychiatry, and early-onset services, a renewed interest
in meeting long-term care needs is likely. Despite the success
of the hospital closure program, people are again accumulat-
ing in highly expensive long-stay beds, often in conditions of
security. Some long-stay patient groups are causing special
concern, because their needs are clearly not well met—nota-
bly women and patients with personality disorders. The dis-
covery of the virtual mental hospital that exists in many
localities provides a powerful logic for the development and
expansion of local rehabilitation and continuing care services.
It is unclear whether the assertive outreach teams required in
the PIG will be subsumed within wider rehabilitation services,
will lie within generic CMHTs, or, as in the Northern Bir-
mingham model, will function as separate entities. An exten-
sive research agenda remains surrounding the further
development of effective treatments and the management of
services for those whose response to treatment is incomplete
and for those requiring continued long-term highly supportive
care. Most challenging of all is the task of ensuring that front-
line staff are trained in and make use of the effective psycho-
social interventions that do exist (62).
References
1. Watts FN, Bennett DH, editors. Theory and practice of psychiatric rehabilitation.
Chichester: Wiley; 1983.
2. Bennett D.H. The historical development of rehabilitation services. In: Watts FN,
Bennett DH, editors. Theory and practice of psychiatric rehabilitation. Chiches-
ter: Wiley; 1983. p 15– 42.
3. Wolfensberger W. Social role valorization: a proposed new term for the principle
of normalization. Ment Retard 1983;21:234 –9.
4. Holloway F. The concept of need in community psychiatry: a consensus is re-
quired. Psychiatr Bull 1994;18:321–3.
5. Wykes T, Holloway F. Community rehabilitation: past failures and future pros-
pects. Int Rev Psychiatry 2000;12:197–205.
6. Abbott P. Reconfiguration of the high security hospitals: some lessons from the
mental hospital retraction and reprovision programme in the United Kingdom
1960-2000. Journal of Forensic Psychiatry 2002;13:107–22.
7. Anthony WA, Cohen MR, and Cohen BF. Psychiatric rehabilitation. In: Talbott
JA, editor. The chronic mental patient. Five years later. New York: Grune and
Stratton; 1984. p 137–57.
W Can J Psychiatry, Vol 47, No 7, September 2002
8. Shepherd G. Foreword. Psychiatric rehabilitation for the 1990s. In: Watts FN,
Bennett DH, editors. Theory and practice of psychiatric rehabilitation. 2nd edi-
tion. Chichester: Wiley; 1991. p xiii–xlviii.
9. Bustillo JR, Lauriello J, Horan WP, Keith SJ. The psychological treatment of
schizophrenia: an update. Am J Psychiatry 2001;158:163–75.
10. Egan B. Special report comparing health systems. Prospect 2002;4:46–52.
11. Goldberg D, Huxley P. Common mental disorders. London: Routledge; 1992.
12. Holloway F. Community psychiatric care: from libertarianism to coercion.
“Moral panic” and mental health policy in Britain. Health Care Analysis
1996;4:235–43.
13. Secretary of State for Health. The NHS Plan. London: Stationery Office; 2000.
CM4818-1.
14. Department of Health Mental Health Information Strategy. London: Department
of Health; 2001.
15. Department of Health. A first class service. Quality in the new NHS. London:
Department of Health; 1998.
16. National Institute for Clinical Excellence Guidance on the use of newer (atypi-
cal) antipsychotic drugs for the treatment of schizophrenia. Technology Ap-
praisal Guidance No 43. London: National Institute for Clinical Excellence;
2002.
17. Holloway F. The inspector calls: CHI comes to town. Psychiatr Bull
1998;25:457–8.
18. Secretary of State for Health. Modernising mental health services. Safe, sound
and supportive. London: Department of Health; 1998.
19. Secretary of State for Health and Home Secretary. Reforming the Mental Health
Act. London: Stationery Office; 2000. Cm 5016-I.
20. Department of Health National Service Framework for Mental Health. Modern
standards and service models. London: Department of Health; 1999.
21. Department of Health Effective Care Co-ordination in Mental Health Services. A
Policy Booklet. London: Department of Health; 1999.
22. Appleby J, Shaw J, Sherratt J, Amos T, Robinson J , McDonnell R, and others.
Safety first: five year report of the National Confidential Inquiry into homicides
and suicides by people with a mental illness. London: Department of Health;
2001.
23. Holloway F. The 5-year report of the National Confidential Inquiry into Suicide
and Homicide by people with mental illness I: clinical practice. Journal of Foren-
sic Psychiatry 2002;13:131–7.
24. Taylor PJ, Gunn J. Homicides by people with mental illness: myth and reality. Br
J Psychiatry1999;174:9–14.
25. Department of Health. The Mental Health Policy Implementation Guide.London:
Department of Health; 2001.
26. Sainsbury Centre for Mental Health. Keys to engagement. Review of care for
people with severe mental illness who are hard to engage with services. London:
Sainsbury Centre; 1998.
27. Stein LI, Test MA. Alternatives to mental hospital treatment! Conceptual model,
treatment program and clinical evaluation. Arch Gen Psychiatry 1980;37:392–7.
28. Birchwood M, Fowler D, Jackson C, editors. Early intervention in psychosis.
Chichester: Wiley; 2000.
29. Leff J, editor. Care in the community – illusion or reality? Chichester: Wiley;
1997.
30. Leff J, Treiman N. Long-stay patients discharged from psychiatric hospitals. Br J
Psychiatry 2000;176:217–23.
31. Lelliott P, Wing J. A national audit of new long-stay psychiatric patients II: im-
pact on services. Br J Psychiatry 1994;165:170–8.
32. Holloway F, Wykes T, Petch E, Lewis-Cole K. The new long stay in an inner
city service: a tale of two cohorts. Int J Soc Psychiatry 1999;45:93–102.
33. Wing JK, Brown GW. Institutionalism and schizophrenia. Cambridge: Cam-
bridge University Press; 1970.
34. Martin JP. Hospitals in trouble. Oxford: Blackwell; 1984.
35. Nicoll MM, Robertson L, Connaughton JA. Life skills programmes for chronic
mental illness. The Cochrane Library: Oxford. Update Software; 2002.
36. Treiman N, Leff J. The difficult to place patients in a psychiatric hospital closure
programme. The TAPS Project, 24. Psychol Med 1996;25:765–74.
37. Wykes T, Wing JK. A ward in a house: accommodation for “new” long-stay pa-
tients. Acta Pychiatr Scand 1982;65:315–30.
38. Hyde C, Bridges K, Goldberg D, Lowson K, Sterling C, Farragher B, and others.
The evaluation of a hostel ward: a controlled study using modified cost-benefit
analysis. Br J Psychiatry 1987;151:805–12.
39. Cullen D, Carson J, Holloway F, Towey A, Jumbo A, Smellie N, and others.
Community and hospital residential care: a comparative evaluation. Irish J Psy-
chol Med 1998;14:92–8.
40. Muijen M, Marks IM, Connolly J, Audini B, McNamee G. The daily living pro-
gramme. Preliminary comparison of community versus hospital-based treatment
for the seriously mentally ill facing emergency admission. Br J Psychiatry
1992;160:379–84.
41. Holloway F, Carson J. Intensive case management for the severely mentally ill.
A controlled trial. Br J Psychiatry 1998;172:19–22.
42. Thornicroft G, Wykes T, Holloway F, Johnson S, Szmukler G. From efficacy to
effectiveness in community mental health services: the PRiSM Psychosis Study
(10). Br J Psychiatry 1998;173:423–6.
633
The Canadian Journal of Psychiatry—In Review

43. Burns T, Creed F, Fahy T , Thomson S, White I. Intensive versus standard case
management for severe psychotic illness: a randomised trial. Lancet
1999;353:2185–9.
44. Marshall M. Bond G. Stein LI, Shepherd G, McGrew J, Hoult J, and others.
PRiSM Psychosis Study. Design limitations, questionable conclusions. Br J Psy-
chiatry 1999;175:501–3.
45. Sashidharan SP, Smyth M, Owen A. PRiSM Psychosis Study. Thro’ a glass
darkly: a distorted appraisal of community care. Br J Psychiatry 1999;75:504–7.
46. Burns T, Fioritti A, Holloway F, Malm U, Rossler W. Case management in
Europe. Psychiatric Services 2001;52:631–6.
47. Brown GW, Rutter M. The measurement of family activities and relationships: a
methodological study. Human Relations 1966;(Suppl 2):10–5.
48. Leff J, Kuipers L, Berkowitz R, Berlein-Vries R, Sturgeon D. A controlled trial
of intervention in the families of schizophrenic patients. Br J Psychia-
try1982;141:121–34.
49. Leff J, Berkowitz R, Shavit N, Strachan A, Glass I, Vaughn C. A trial of family
therapy versus a relatives’ group for schizophrenia: two-year follow-up. Br J
Psychiatry 1990;157:571–7.
50. Tarrier N, Barrowclough C, Porceddu K, Fitzpatrick E. The Salford family inter-
vention project: relapse rates of schizophrenia at five and eight years. Br J Psy-
chiatry 1994;165:829–32.
51. Barbato A, D’Avanzo B. Family interventions in schizophrenia and related disor-
ders: a critical review of clinical trials. Acta Psychiatr Scand 2000;102:81–97.
52. Kuipers E, Garety P, Fowler D, Dunn G, Bebbington P, Freeman D, and others.
London-East Anglia randomised control trial of cognitive behavioural therapy for
psychosis I: effects of treatment phase. Br J Psychiatry 1997;171:319–27.
53. Tarrier N, Yusupoff L, Kinney C, McCarthy E, Gledhill A Haddock J, and oth-
ers. Randomised controlled trial of intensive cognitive behaviour therapy for pa-
tients with chronic schizophrenia. BMJ 1998;317:303–7.
54. Sensky T, Turkington D, Kingdon D, Scott JL, Scot J, Siddle R, and others. A
randomised controlled trial of cognitive-behavioural therapy for persistent symp-
toms in schizophrenia resistant to medication. Arch Gen Psychiatry
2000;57:165–72.
55. Drury V, Birchwood M, Cochrane R, MacMillan F. Cognitive therapy and recov-
ery from acute psychosis: a controlled trial 1: impact on psychotic symptoms. Br
J Psychiatry 1996;169:593–601.
56. Kemp R, Kirov G, Everitt B, Hayward P, David A. Randomised controlled trial
of compliance therapy. 18 month follow-up. Br J Psychiatry 1998;172:413–9.
57. Birchwood M, Smith J, Macmillan F, Hogg B, Prasad R Harvey C, and others.
Predicting relapse in schizophrenia: the development and implementation of an
early signs monitoring system using patients and families as observers. Psychol
Med 1989;19:649–56.
58. Spencer E, Murray E, Plaistow J. Relapse prevention in early psychosis. In:
Birchwood M, Fowler D, Jackson C, editors. Early intervention in psychosis.
Chichester: Wiley; 2000. p 236–60.
59. Wykes T, Reeder C, Corner J, Williams C, Everitt B. The effects of neurocogni-
tive remediation on executive processing in patients with schizophrenia.
Schizophr Bull 1999;25:291–308.
60. Barrowclough C, Haddock G, Tarrier N, Lewis SW, Moring J, O’Brien R, and
others. Randomized controlled trial of motivational interviewing, cognitive be-
havior therapy, and family intervention for patients with comorbid schizophrenia
and substance use disorders. Am J Psychiatry 2001;158:1706–13.
61. Department of Health. The journey to recovery: the government’s vision for
mental health care. London: Department of Health; 2001.
62. Brooker C. A decade of evidence-based training for work with people with seri-
ous mental health problems: progress in the development of psychosocial inter-
ventions. Journal of Mental Health 2001;10:17–31.
Manuscript received and accepted July 2002.
1
Consultant Psychiatrist, Bethlem Royal Hospital, Monks Orchard Road,
Beckenham, Kent, UK.
2
Senior Lecturer in Clinical Psychology, Institute of Psychiatry, De
Crespigny Park, London, UK.
3
Senior Occupational Therapist, Westways Rehabilitation Unit, Croydon
CR0 2UR.
Address for correspondence: Dr F Holloway, Bethlem Royal Hospital,
Monks Orchard Road, Beckenham, Kent, BR4 0HD, UK
e-mail: f.holloway@iop.kcl.ac.uk

Résumé : Réadaptation au Royaume-Uni : recherche, politiques et pratiques

Objectif : Examiner la recherche, les politiques et les pratiques en matière de réadaptation psychiatri-
que au Royaume-Uni.
Méthode : Une revue de la documentation ainsi qu’une revue des documents politiques du gouverne-
ment ont été entreprises.
Résultats : La plupart des personnes qui souffrent de maladies mentales graves et invalidantes sont
sous les soins de services de santé mentale communautaires génériques en vertu du Care Programme
Approach (CPA). La politique en vigueur du gouvernement exige que soient instaurés des services de
suivi intensif dans la communauté et de traitement précoce de la psychose. Cela correspond tout à fait
à l’adoption d’un paradigme de rétablissement au sein des services de santé mentale britanniques. Les
activités de recherche et développement ont démontré le succès du programme britannique de ferme-
ture des hôpitaux et ont contribué au renouveau d’intérêt mondial pour les interventions psychosocia-
les sur la psychose.
Conclusions : Il faut encore axer davantage la recherche sur les personnes qui sont le plus frappées
d’incapacité par leur maladie, et améliorer les compétences de la main-d’oeuvre des interventions
psychosociales.

634
W Can J Psychiatry, Vol 47, No 7, September 2002