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International Review of Psychiatry, April 2010; 22(2): 114129

Psychiatric rehabilitation interventions: A review

MARIANNE FARKAS & WILLIAM A. ANTHONY


Center for Psychiatric Rehabilitation, Boston University, USA

Abstract Psychiatric rehabilitation has become accepted by the mental health field as a legitimate field of study and practice. Over the last several decades various psychiatric rehabilitation programme models and procedures have been developed, evaluated and disseminated. At the same time the process of psychiatric rehabilitation has been specified and its underlying values and practitioner technology articulated. This review describes the psychiatric rehabilitation process and in so doing differentiates psychosocial interventions that can be classified as psychiatric rehabilitation interventions from other psychosocial interventions. Furthermore, the major psychiatric rehabilitation interventions are examined within a framework of the psychiatric rehabilitation process with a review of their evidence. The review concludes that psychiatric rehabilitation interventions are currently a mixture of evidence-based practices, promising practices and emerging methods that can be effectively tied together using the psychiatric rehabilitation process framework of helping individuals with serious mental illnesses choose, get and keep valued roles, and together with complementary treatment orientated psychosocial interventions, provide a broad strategy for facilitating recovery.

Introduction The mental health field has accepted psychiatric rehabilitation as one of the preferred methods for helping individuals with serious psychiatric disabilities (Anthony, Cohen, Farkas, & Gagne, 2002; Rossler, 2006). Nevertheless, it remains less clearly understood or effectively practiced due in part to the fact that many types of mental health practitioners, including psychiatric rehabilitation practitioners, deliver psychiatric rehabilitation. In addition, relevant research and conceptual articles appear in a wide range of professional journals. The terms psychosocial interventions and psychiatric rehabilitation have come mistakenly to be used interchangeably, a confusion which has led some researchers to complain that there is no consistent method to categorize psychosocial treatment (Dixon et al., 2009). The broad disabilities associated with mental illnesses cannot be addressed with a single focused intervention alone. Psychiatric rehabilitation is a field, not just a series of unique interventions or programme models. It has a defined set of values, techniques, programme practices and relevant outcomes developed over the past thirty years

(e.g. Anthony et al., 2002; Farkas & Anthony, 1989; Pratt, Gill, Barrett, & Roberts, 2007). This article clarifies psychiatric rehabilitation in its current context, presents a coherent framework for organizing psychosocial interventions and reviews the interventions associated with it. The individuals who are the focus of psychiatric rehabilitation Individuals who are the focus of psychiatric rehabilitation services share a diagnosis of mental illness usually of more than two years duration since diagnosis and a pronounced limitation in residential, vocational, social or educational role functioning (Schinnar, Rothbard, Kanter, & Jung, 1990). Within this group of people are subgroups, such as young adults (e.g. Bachrach, 1982; Harris & Bergman, 1987; Pepper & Ryglewicz, 1984), patients from minority cultures (Ruiz, 1997), patients who are homeless (e.g. Farr, 1984; Salit, Kuhn, Hartz, Vu, & Mosso, 1998) or otherwise impoverished (e.g. Ware & Goldfinger, 1997), older citizens (e.g. Gaitz, 1984), patients with both a severe physical disability and severe psychiatric disability (e.g. Pelletier,

Correspondence: Marianne Farkas, Center for Psychiatric Rehabilitation, Boston University, 940 Commonwealth Avenue West, Boston, MA 02215, USA. Tel: 617 353 3549. Fax: 617 353 7700. E-mail: mfarkas@bu.edu ISSN 09540261 print/ISSN 13691627 online 2010 Institute of Psychiatry DOI: 10.3109/09540261003730372

Psychiatric rehabilitation interventions: A review Rogers, & Dellario, 1985), and patients with substance abuse problems (e.g. Lehman, 1996; US Department of Health and Human Services, 1994). This article uses the terms individuals with serious mental illnesses, individuals with lived experience or people interchangeably with clients or consumers to refer to the target population. The term individual or person underscores rehabilitations interest in the human being, across all of his or her roles (e.g. resident, student, worker, friend). Individuals who themselves have mental illnesses use the term lived experience (Deegan, 1988) to emphasize a commonality based on experience, rather than on labels or the acceptance of any one explanation of serious mental illnesses.

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Definition of psychiatric rehabilitation in the context of recovery Psychiatric rehabilitation ( PR) is neither a particular technique nor one intervention but a field and a service within a mental health system, along with other services such as treatment services, crisis intervention services or basic support services. Since recovery is a consumer experience and not a programme model or provider practice, no service can do recovery. Psychiatric rehabilitation can and does promote a vision of recovery or the achievement of a meaningful life, rather than simply supporting adaptation or survival in the community ( Farkas, 2007). Typically, recovery outcomes have included multidimensional variables ranging from as an increase in physical health and well-being to gaining or regaining valued societal roles, and reducing symptoms ( Farkas et al., 2005). Each type of service within a recovery orientated mental health system should therefore be able to clearly identify the recovery outcomes for which it holds itself responsible. For example, treatment services can contribute to recovery by reducing symptoms and distress, whatever other functions they may perform. In this context, psychiatric rehabilitation services contribute to recovery by focusing on outcomes related to role functioning in real world settings chosen by the individual (Anthony et al., 2002). Rehabilitation operates at the intersection between the individual, an individuals personal network and the wider social context ( Barbato, 2006). Rehabilitation, of any kind (i.e. physical, psychiatric, social, etc.) is ecological (personenvironment fit) and specifically targets improving role performance. The term psychiatric rehabilitation reflects the focus of this field on people with psychiatric disabilities and their improved abilities within their specific preferred role in the real world, using the development of skills and supports as its primary types of interventions (Anthony et al., 2002; Farkas, 2006). Without a process committed to supporting chosen roles and settings, functioning may be improved but the individuals vision of a meaningful life may still not be achieved. Rehabilitation, therefore, works with social relationships, work, leisure, family life, higher education and other student pursuits, using interventions that focus on increasing competencies or skills and providing environmental supports, rather than focusing on symptoms and pathology. It does not deny that symptoms and pathology exist nor the importance of intervening to reduce these, however its own expertise targets the International Classification of Impairment, Disability and Handicap ( ICIDH) dimensions of activity, participation and environment (WHO, 2001), rather than health.

Context In contrast to the practice of psychiatric rehabilitation, service delivery over most of the last century has generally been heavily influenced by the mistaken assumption that people with severe mental illnesses do not recover and, in contrast, deteriorate over time ( Bond et al., 2001; Farkas, Gagne, Anthony, & Chamberlin, 2005). There is a growing body of literature examining the concept of recovery from mental illnesses and its outcomes (e.g. Anthony, 1993; Davidson, Harding, & Spaniol, 2005; Farkas, 2007; Harding & Zahniser, 1994; Liberman, Kopelowicz, Ventura, & Gutkind, 2002; Ridgway, 2001; Silverstein & Bellack, 2008; Spaniol, Wewiorski, Gagne, & Anthony, 2002). People with psychiatric disabilities have published their experiences of recovery (e.g. Deegan, 1990, 1993; Fisher & Ahern, 1999; Mead & Copeland, 2000; Ridgway, 2001; Spaniol, Gagne, & Koehler, 1999), and with like-minded professionals are advocating for system and agency strategies to facilitate recovery (e.g. Frese, Stanley, Kress, & Vogel-Scibilia, 2001; Jacobson & Greenley, 2001; Torgalsboen & Rund, 1998). Clearly, people with psychiatric disabilities have the same aspirations as any other citizen for respect and as fulfilling a life as possible. Thirty years of empirical evidence as well as first person accounts support the notion that recovery from serious mental illnesses or the gaining or regaining of a meaningful life is not only desirable but possible. Recovery is acknowledged to be the patients experience of a journey from the catastrophic effects of mental illness to a meaningful life and full citizenship (Deegan, 1990; Farkas, 2007; Ridgway, 2001). Contributing to this journey and multidimensional outcomes is now promulgated as the necessary unifying mission of all mental health services ( Farkas et al., 2005; New Freedom Commission on Mental Health, 2003).

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M. Farkas & W A. Anthony . to assess non-RCT studies has been subsequently developed to ensure the quality of research information disseminated in this field ( Farkas & Rogers, 2007). A review of PR interventions must therefore take into account the aim of psychiatric rehabilitation (i.e. improving role performance in a chosen environment) within the overall mission of enhancing recovery, the recovery orientated values which define the strategies used as well as include both RCTs and non-RCTs as legitimate designs for a low incidence, complex, ecological field.

The cornerstone of PR interventions is a commitment to a strong partnership between the provider and the individual receiving services. Psychiatric rehabilitation values the involvement of individuals with lived experience in the design, implementation and evaluation of their own rehabilitation process as well as services (i.e. Nothing about us without us). It uses methods that focus on the person as a whole rather than on a case, individualize the process and its outcomes, promotes self determination, hope and the importance of choice all values consistent with the vision of recovery (Farkas, 2006, 2007). To be classified a psychiatric rehabilitation PR intervention, an intervention should, therefore, be based on these recovery orientated values, while helping individuals to change (i.e. building skills) or changing the environment (i.e. supports) in relation to achieving a specific preferred role.

A framework for the psychiatric rehabilitation process and the review An overall framework known as the psychiatric rehabilitation approach to serving individuals with serious psychiatric disabilities was developed at Boston Universitys Center for Psychiatric Rehabilitation (Anthony, 1979; Anthony et al., 2002; Farkas & Anthony, 1989). Compared to well-known programme models in the mental health field, the psychiatric rehabilitation process approach is not setting-specific, nor is it tied to a particular staffing pattern. In contrast to a specific emphasis with respect to discipline, setting, or service integration, the psychiatric rehabilitation approach guides practitioners to develop a personal connection with individuals with serious mental illnesses to facilitate, support or teach indiiduals how to choose, get, and keep a preferred role valued by society (Anthony & Farkas, 2009). The approach defines the process both from the frame of reference of the person served and from the providers point of reference. Figure 1 identifies the major provider activities that facilitate the different elements of the choose-get-keep process. Individual PR interventions can be described in terms of the elements of the process they accomplish.
Keeping a valued role Assessing critical skill and/or support strengths and deficits

Research in psychiatric rehabilitation The field of psychiatric rehabilitation is still at an early stage of conducting research on the interventions that constitute it. While well-executed, randomized clinical trials (RCTs) are considered the gold standard for rigorous research, the limitations of RCTs, especially in the psychosocial intervention arena have been well documented (Anthony, Rogers, & Farkas, 2003; Essock et al., 2003). Limitations such as small sample sizes available for the complexity of the variables are particularly acute when the goal is multidimensional, such as recovery, as opposed to more limited outcomes such as the prevention of relapse, or re-hospitalization for example. Researchers have called for the inclusion of a broader variety of research designs that are more consonant with the multidimensionality of recovery and the state of our current understanding (Anthony et al., 2003; Essock et al., 2003). A grading scheme
Choosing a valued role

Getting a valued role Linking with existing worker/worker/student/ residential/social role opportunities

Engaging

Provider Process

Assessing and developing readiness Creating worker/worker/student/ residential/social role opportunities

Person-centred planning Developing skills to succeed in the preferred role Developing supports to succeed in the preferred role

Setting an overall goal

Figure 1. Process framework for psychiatric rehabilitation, person level process.

Psychiatric rehabilitation interventions: A review Choosing phase The choosing process is designed to help individuals engage as full partners in determining where and in what role they want to live, learn, work or socialize. Beginning rehabilitation with this process helps to establish the individuals hopes for a future, rather than beginning with an assessment of strengths and deficits and then determining a goal that fits. Starting with a choice empowers individuals with serious mental illnesses to take control of their rehabilitation and ensures that the goals of rehabilitation are indeed related to their own vision of their recovery. Putting the individual receiving services at the centre of care and supporting that persons autonomy is seen as a basic underlying premise for the provision of modern healthcare in general (Grol, 2001; Sensky, 2002). Further, research data suggests that involving individuals in the planning of their services improves rehabilitation outcome (Majumder, Walls, & Fullmer, 1998). While there is evidence that has shown that offering choice and shared decision making is more effective than traditional authoritarian approaches to treatment (Priebe et al., 2007), the issue of providing choice as a cornerstone of rehabilitation is more a question of rights and full citizenship in society, rather than simply about evidence. Crawford et al. (2003) note that several European countries have passed legislation to ensure that the notions of self determination, choice and autonomy are translated into action in the healthcare field. The major provider components leading to an individuals active choice of role and setting in psychiatric rehabilitation are engagement, readiness and setting an overall goal. Engagement The choosing process is not a simplistic interchange where the individual simply lists his or her needs and desires. It involves engaging the person in a partnership. Some engagement techniques used to demonstrate partnership, caring and respect include accompanying the person in concrete activities (e.g. sports or drinking coffee), as well as empathy, which has long been recognized as a necessary component of the therapeutic relationship in psychological interventions with many populations (e.g., Anthony, 1993; Anthony et al., 2002; Battaglia, Finley, & Liebschutz, 2003; Kirsh & Tate, 2006). Studies report that the individuals perception of the relationship is a consistent predictor of improvement (Bachelor, 1995; Goering, Wasylenki, Farkas, Lancee, & Ballantyne, 1988). The key to effective outcomes may well lie with the establishment of an engaged partnership between the provider and the

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individual, although the research literature with respect to the role of relationships or working alliance and specific outcomes for people with serious mental illnesses is still sparse and in its infancy (Howgego, Yellowlees, Owen, Meldrum, & Dark, 2003; Lehman et al., 2004). Readiness The second critical element of the choosing process is providing an opportunity for an individual to assess the extent to which s/he is ready to begin to make a change. People vary in their willingness to confront change of any kind, including the types of changes implied in the psychiatric rehabilitation process (i.e. gaining or improving a valued role in society) (Farkas, Sullivan-Soydan, & Gagne, 2000b). The process may challenge people to make behavioural or lifestyle changes. Changing from one role (e.g. hospital patient) to another (e.g. university student) may require a person to process many changes simultaneously (e.g. change in identity, social relationships, level of energy expended daily, behavioural changes). The readiness to face the reality of making a decision about the future (i.e. job, school, home, friends) and finding the will to do whatever it takes to make that choice can be overwhelming, but is not immutable. Readiness is a condition that changes as internal and external factors change. Prochaska and colleagues have developed a model for readiness for change that provides guidance in helping a person understand their current stage of readiness (i.e. pre-contemplation through action and maintenance) (Prochaska, DiClemente, & Norcross, 1992). Farkas, Cohen, McNamara, Nemec, and Cohen (2000a) developed methods to facilitate the individuals own assessment of various factors (i.e. need for change, commitment to change, their self- and environmental awareness and preference for closeness) related to the stages of readiness and then to identify the necessary next steps. Developing readiness for those who are not prepared to make changes or are very unsure about their current readiness can involve various strategies, depending on the readiness factors that are holding the individual back. For example, techniques such as motivational interviewing (Miller & Rollnick, 2002) have been shown to be effective in improving commitment to change (Hettema, Steele, & Miller, 2005). Programmes where people with serious mental illnesses are members of a social group whose functioning depends on their performance of certain tasks, such as Fountain House clubhouses (Beard, Propst, & Malamud, 1982; McKay et al., 2006), can also be effective in promoting a sense of connection or support ( Norman, 2006) and task

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M. Farkas & W A. Anthony . within the Fountain House model, supported employment or supported education also can be helpful to the individual in providing a better understanding of what is personally important, especially for those with little work or school history. These personal criteria are critical to the persons ability to identify meaningful long term school or career goals. In addition to identifying clear personal criteria for making a choice, people need a structured problem-solving method to come to a decision about their goals. Shared decision making, one such popular method, is essentially a negotiation between the provider and the individual, based on education about options and consequences ( Deegan, Rapp, Holter, & Riefer, 2008). A recent review of the literature in shared decision making in medical practice suggested that such tools can be effective to increase engagement and satisfaction with services ( Joosten, et al., 2008). Shared decision making has also been suggested as useful for rehabilitation goal setting ( Drake et al., 2009b), however, such an application does not correspond to the values of self-determination in recovery and rehabilitation. While some decisions, like medication choices should be shared, decisions about goals are truly personal statements of meaning and future hopes. These do not lend themselves to negotiated solutions, but rather to techniques that assist the person to make a well informed choice followed by targeted rehabilitation interventions to achieve the demands of the selected desired roles. Getting phase The getting process involves intervening in the environment to help people link with opportunities that exist or to help create more opportunities in order to obtain the roles they want. One major barrier to getting a job, housing, education or a social environment is stigma. Numerous studies have examined the role of stigma in diminishing access to societal opportunities for individuals with serious mental illnesses, as well as the negative consequences of labelling on the individual (e.g. Corrigan, Green, Lundin, Kubiak, & Penn, 2001; Gaebel, Baumann, Witte, & Zaeske, 2002; Jorm, 2000; Lauber, Nordt, Falcato, & Roessler, 2004; Link, Struening, Rahav, Phelan, & Nuttbrock, 1997; Mueller et al., 2006). Interventions designed to reduce stigma can be categorized in three strategies: education, contact and protest. Even though programmes that target specific groups (e.g. students, or police) do appear to strengthen educational anti-stigma programmes (Corrigan & Penn, 1999; Holmes, Corrigan, Williams, Canar, & Kubiak, 1999; Pinfold et al., 2003), it is generally agreed that education alone is

orientation ( Yau, Chan, Chan, & Chui, 2005) among other factors, that in turn can lead to a greater sense of readiness to make changes ( Farkas et al., 2000b). In addition, success at small but important tasks in a clubhouse environment can increase a sense of self-efficacy which also contributes to a greater commitment to change. Educational seminars about mental illnesses and the possibilities of recovery and support from peers who can serve as role models, are additional techniques that have been used to increase readiness for change (Cohen, Anthony, & Farkas, 1997; Cohen, Forbess, & Farkas, 2000). Peer support has been found to improve a sense of self-efficacy in one of the first RCTs done on peer support groups (Castelein et al., 2008). Setting an overall goal Setting an overall goal specifies the preferred valued role and setting, an initial and critical part of rehabilitation driving the rest of the process. These personally meaningful goals provide the framework for the later identification of critical skills and supports that will be needed for success and satisfaction, for example, as a part-time carpenter, a student at the local community college or the treasurer for a local club. To set such a goal, a provider can facilitate individual identifying personal criteria for making a decision; researching alternatives and using a structured problem solving method to select the role and setting the person wants to achieve over an 18-month to two-year period (Anthony et al., 2002; Cohen, Farkas, Cohen, & Unger, 1991). This overall goal motivates the individual by setting a meaningful target to achieve, linked to his/her personal vision of what recovery would look like. In a randomized clinical trial using Boston Universitys technology for training providers to set overall rehabilitation goals (Cohen et al., 1991), Shern et al. (2000) compared experimental participants who were homeless, street dwelling and mentally ill, to a similar group who received standard treatment. Participants in the psychiatric rehabilitation condition where the collaborative goal setting process was emphasized spent less time on the streets and more time in community housing. Supported employment (Drake et al., 1994) and supported education (Mowbray, Brown, Sullivan-Soydan, & Furlong-Norman, 2002) are rehabilitation interventions which rapidly place the individual in competitive employment or normative educational programmes (e.g. high school, university, apprenticeship) and then provide support and training to keep the person in that role. While not designed for this purpose, concrete, real world experiences gained in interventions such as transitional employment

Psychiatric rehabilitation interventions: A review not enough (Stuart, Arboleda-Florez, & Sartorius, 2005). Strategies involving contact between people with lived experience and others provide a personal experience of those with mental illnesses, breaking down stereotypes and countering negative beliefs ( Vaughan & Hansen, 2004). In a review of the research on contact, Couture and Penn (2003), conclude that contact has positive effects, especially with respect to reducing the stigma due to perceived dangerousness, fear and social distance. A strong argument in favour of psychiatric rehabilitations focus on real world settings and socially valued roles is the positive impact that contact between those with and without psychiatric disabilities has on reducing social distance ( Lauber et al., 2004). The third method, social protest (Corrigan & Penn, 1999), has had only mixed results. Interventions that include education, contact and the development of the commitment to action by a specific group or groups have been suggested as the most powerful stigma reduction strategy (Pinfold, Thornicroft, Huxley, & Farmer, 2005). Obtaining a valued role in the community involves more than reducing stigma. It also involves increasing the number of settings and opportunities. There is a growing body of sound research studies ( Barbato, 2006) demonstrating the significant role that social and environmental risk factors play in maintaining psychiatric disabilities, such as migration and urban living, among others (Cantor & Selten, 2005; van Os, Hansen, Bijl, & Vollebergh, 2001). Research has only begun to be done on strategies such as community development, advocacy, and job development in terms of their use in PR to overcome these risk factors and other barriers in order to provide more opportunities. One example of such research is a recent multi-site randomized clinical trial found that individuals who received job development services were five times as likely to get competitive employment as those who did not (Cook et al., 2008). Keeping phase Assessing and planning. Keeping valued roles is the third critical component of the psychiatric rehabilitation process. The keeping process is based on the principle that improving skills and/or supports critical to functioning in the persons chosen role leads to success and satisfaction. For example, if the chosen role is that of a part-time cleaner in an office building, the skill of evaluating task completion may be critical, while perhaps interpersonal skills are not as important. Cleaning supplies and transportation to the job may be critical resources. If the chosen role is that of a room-mate in a rented flat, the skill of evaluating task completion may be

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irrelevant, while the skill of negotiating conflict may be critical depending on the roommates specific characteristics. Having money for rent is a critical resource, while having transportation may not be. Standardized functional assessments and checklists unfortunately do not permit the individualization and specificity relative to environmental demands that are necessary to devise appropriate rehabilitation interventions ( Farkas, OBrien, Cohen, & Anthony, 1994). Interventions need to be planned to overcome the specific skill and resources assessed both as deficits and critical to the valued role selected in the choosing phase. Skill development interventions The evidence that people with serious mental illnesses can learn skills is robust ( Dilk & Bond, 1996; Kopelowicz, Liberman, & Zarate, 2006; Kurtz & Mueser, 2008). Social skills training (SST ) is perhaps the best known skills training method ( Bellack, 2004; Kopelowicz et al., 2006; Liberman, 1998). The content of the SST modules includes both treatment orientated training programmes (e.g. medication management, substance abuse management) ( Wallace, Liberman, MacKain, Blackwell, & Eckman, 1992) and rehabilitation orientated programmes (e.g. community re-entry and work-place fundamentals) (Liberman et al., 1998). Studies have been conducted in diverse treatment settings, by diverse practitioners covering a defined set of skills (e.g. Bellack, 2004; Heinssen, Liberman, & Kopelowicz, 2000; Xiang et al., 2007). Kurtz and Mueser (2008) report significant effects on role play tests as well as measures of community functioning, concluding, however, that the number of studies that include follow-up data is too small to be confident about the durability of these effects. Based on the preponderance of the evidence, Dixon et al. (2009) recommend that individuals with schizophrenia with deficits in skills needed for everyday activities should be offered skills training that is supplemented with strategies for ensuring adequate practice in applying these skills to everyday life. Most skills training, however, including SST, puts participants in a passive role where they are recipients of reinforcers and information designed to help them perform behaviours, that providers or significant others deem important ( Ellison et al., 2002; Shern et al., 2000). The Center for Psychiatric Rehabilitation designed a method called direct skills teaching (DST), that systematically incorporates basic educational and cognitive techniques so that providers can outline the knowledge needed to learn any relevant skill, develop a structured lesson plan to teach each component behaviour and involve the person and individuals in the relevant environment

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M. Farkas & W A. Anthony . accommodate the individuals lack of skill, so that this gap does not result in the person being unable to perform successfully in his or her chosen role. For example, a person who cannot remember appointments may use a wrist watch that buzzes at the time of the appointment as a reminder. Someone who cannot drive or use public transportation may use a relative or friend to drive them to school. Case management interventions help individuals obtain and use the supports they want and need. Rehabilitation case management links people with mental illnesses to resources that will help them to achieve the specific valued role they seek. The strengths model of case management (SMCM) (Rapp & Wintersteen, 1989) and the person centred rehabilitation case management (PCRCM) approach (Cohen, Forbess, & Farkas, 1988) focus on strengths to achieve effective links with resources involve individuals as partners in the process and are most congruent with the values of psychiatric rehabilitation. While these have been well disseminated and reviewed (Anthony et al., 2002), the assertive community treatment programme (ACT ) developed by Stein and Test (1980) has been the most investigated. Based on the evidence, the Patient Outcomes Research Team (PORT ) psychosocial treatment recommendations recommend the use of ACT particularly for those who are homeless or who are at risk for repeated hospitalizations ( Dixon et al., 2009). ACT appears to have a positive impact on two rehabilitation outcomes: increased tenure in stable community housing (e.g. Essock & Kontos, 1995; Lehman, Dixon, Kernan, DeForge, & Postrado, 1997; Nelson, Aubrey, & Lafrance, 2007) and more recently, employment outcomes. Studies indicate that when individuals are randomized to ACT teams with employment specialists, they are more likely to have paid employment, be working in competitive employment and are employed for longer periods of time than those in standard treatment (Chandler, Hu, Meisel, McGowen, & Madison, 1997; McFarlane et al., 2000). ACT seems to be most relevant to the USA; however, since its outcomes outside the USA have been shown to be questionable, particularly in countries with integrated service systems (Burns et al., 2007b; Sytema, Wunderlink, Bloemers, Roorda, & Wiersma, 2007). Furthermore, unlike the SMCM and PCRCM, the ACT model seems to promote some values that are not recovery or rehabilitation orientated. For example, its assertive outreach can become coercive in the way in which it is implemented and choice is further diminished in that individuals must work with a team, even if they prefer the privacy of working with one worker (Drake & Deegan, 2008). Besides professional support, support can also be given by non-professionals. Of individuals with

in practice and generalization efforts (Cohen, Danley, & Nemec, 1985b). DST partners with the learner to ensure that only critical skills necessary for functioning in the specific preferred role (rehabilitation goal), and assessed as missing from the persons repertoire, are taught. DST is part of an overall PR promising practice (Rogers, Anthony, & Farkas, 2006) and can be used to modify existing SST in order to increase its congruence with the rehabilitation process of choose-get-keep. Modifications such as preparing for SST by identifying an overall rehabilitation goal, only teaching the assessed critical skills for that goal and modifying the lessons to reflect a teaching process which involves the learner in a partnership, can enhance SST as a rehabilitation intervention. The problem of generalization in social skills has remained a thorny one. Emerging strategies seem to be converging on the principles of direct skills teaching (Cohen, Ridley, & Cohen, 1985a). They suggest, and research has confirmed, that facilitating the application of trained skills in everyday environments is more effective than simply providing homework practices (Glynn et al., 2002; Xiang et al., 2007). Strategies such as incorporating trainer-guided community-based practice and training family members or other natural supports to help with generalization hold promise (Glynn et al., 2002; Kopelowicz, Zarate, Gonzalez Smith, Mintz, & Liberman, 2003). Another type of skill development is the group of behavioural interventions known as cognitive remediation. Cognitive deficits are common for individuals with serious mental illnesses and often impede work, social relationships and independent living (McGurk, Twamley, Sitzer, McHugo, & Mueser, 2007). Cognitive remediation specifically targets skills in areas such as memory, attention and reasoning to improve daily functioning. A recent meta-analysis of 26 randomized controlled trials of cognitive remediation including 1,151 subjects with schizophrenia, concluded that these techniques produce moderate improvements in cognitive performance which, when combined with psychiatric rehabilitation techniques, also improve functional outcomes (McGurk et al., 2007), such as employment (McGurk, Mueser, DeRosa, & Wolfe, 2009). While identified as a promising practice, Dixon et al. (2009) consider current data on cognitive remediation as sufficient to build further research but not yet sufficient to make concrete, evidence-based clinical recommendations about its use at this time. Support interventions PR support interventions typically involve the use of people, objects, locations or activities that

Psychiatric rehabilitation interventions: A review mental illnesses, 5090% live with their relatives following acute psychiatric treatment (Schulze & Rossler, 2005). The most well-known family support interventions are psycho-education group interventions which typically use education and support to target outcomes for the family care givers themselves (e.g. McFarlane, McNary, Dixon, Hornby, & Cimett, 2001; Pickett-Schenk et al., 2006a), or for the individuals with serious mental illnesses. They have been found effective for outcomes such as levels of knowledge about schizophrenia, improved information needs, improved family relationships, reduced family burden, and improved satisfaction in their caregiver role (Kulhara et al., 2009; Pickett-Schenk et al., 2006a, 2006b; Pickett-Schenk, Lippincott, Bennett, & Steigman, 2008). Briefer family interventions (less than 6 months) that include education, training and support may also improve the functional and vocational status of their family member, among other outcomes (e.g. Xiang, Ran, & Li, 1994). While family education programmes may increase family perceptions of being supported and thus reduce their sense of burden, not all families are equally capable of giving full support to their family member, nor are they necessarily willing to replace insufficient healthcare systems (Koukia & Madianos, 2005; Strachan, 1986). In addition to PR support interventions provided by case managers and family members, peer support has been increasingly recognized as a critical component of a progressive mental health and rehabilitation system. Peer support rests on the belief that people who have faced, endured, and overcome adversity can offer useful support, encouragement and hope to others facing similar situations ( Davidson, Chinman, Sells, & Rowe, 2006). Peers to date have included a wide range of roles from serving as members of regular clinical teams such as ACT, providing peer support specialist services or running independently operated services of their own (Goldstrom et al., 2006). Peers can serve as role models for one another, reducing stigma and removing barriers to accessing housing, employment and education. This variety, while providing flexible vehicles for support, also makes rigorous research more difficult. While the existing data suggests that peer support can be positive (Davidson et al., 2006; Solomon & Draine, 1995), there are very few well controlled studies of the effects of peer support ( Davidson et al., 2006). Davidson and colleagues rightly point out that at this early stage of developing an understanding of peer support, traditional clinical measures (e.g. rehospitalization, symptom reduction) are perhaps inappropriate to evaluate peer services because they may not capture the processes and outcomes of more innovative peer programmes. Moreover, since peer support is fundamental to

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psychiatric rehabilitation values and practice, more research is clearly needed to ascertain the ways in which it is effective and the ingredients of its effectiveness. Other support interventions are based on the fact that most people with psychiatric disabilities want decent housing, meaningful, appropriate education, a meaningful career and satisfying relationships. The best known examples of these interventions are supported employment, supported housing and supported education. These types of interventions tend to combine support with some skill development. The three interventions begin with the premise that it is better to help people access the real world environment of housing, work and school quickly and provide intensive supports in those environments, than to spend lengthy periods of time preparing to enter these settings. All too often in the past, preparation became a dead end and individuals languished in sheltered housing, sheltered workshops and day treatment classes forever. There are many models of vocational rehabilitation which provide support including clubhouses (Beard et al., 1982), client-based industries and social firms ( Warner & Mandiberg, 2006), representing a range ` of options vis a vis the intensity or length of support and the type of competitive employment reflected in its usual options. These are promising practices which focus on providing individuals with experiences and support to do real work for real pay. Supported employment, and particularly the individual placement and support model (IPS) (Drake et al., 1994) which integrates clinical and vocational services, has, however, been the most widely researched. The most recent schizophrenia patient outcomes research team (PORT ) for psychosocial treatments recommends, based on the sufficiency of clinical trials, that any person with schizophrenia with a goal of employment should be offered supported employment, especially IPS (Dixon et al., 2009). Clinical trials have consistently shown the viability and effectiveness of supported employment in a variety of countries and cultures in helping individuals achieve competitive employment, work more hours and earn more wages than those who did not receive IPS (e.g. Burns et al., 2007a; Drake et al., 1994; Drake, Becker, Biesanz, Wyzik, & Torrey, 1996). The extent of job retention with IPS is unclear however, with some studies indicating that rapid entry into employment predicts shorter job tenure (Catty et al., 2008) or has negative job endings (Drake & Bond, 2008), while others suggest that over half of those enrolled in IPS become steady workers over a ten-year follow-up period (Campbell, Bond & Drake, 2009). Programmes that implement IPS without paying attention to the individuals interest

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M. Farkas & W A. Anthony . programmes (Collins et al., 1998), while other preliminary but insufficient data indicates that supported education may increase the educational attainment of individuals with psychiatric disabilities (Mowbray & Collins, 2002; Rogers et al., 2009). In many industrialized countries access to higher education or post-secondary training is considered to be a right of all citizens with the academic or skill qualifications. For this reason alone, more research should be done to add to our preliminary understanding of the effectiveness of supported education as a viable method of improving educational success. Complementary interventions The choosing-getting-keeping valued roles framework helps to sort out those interventions which support the psychiatric rehabilitation process, as compared to those which may use psychosocial tools but are not involved in helping individuals choose, get or keep a specific valued role. The use of psychosocial interventions focused on the reduction of symptoms and effects of the illness itself and that are congruent with recovery and psychiatric rehabilitation values of person orientation, partnership, self determination and hope, while not PR interventions, can be well used in complement with PR to provide comprehensive overall approaches to recovery. Examples of such complementary psychosocial interventions are shared decision making about medications ( Deegan et al., 2008), illness management and recovery (Mueser et al., 2006) and wellness action recovery planning (Copeland, 2002). Implementing psychiatric rehabilitation As is evidenced in this review, psychiatric rehabilitation currently consists of a combination of promising practices and those with sufficient RCTs to qualify as evidence-based practices that focus on helping people achieve a valued role they want, in society. While a detailed discussion of the problems arising when attempting to put PR into practice is outside the purview of this article, several common problems can be summarized. These include an overreliance on practices supported by RCT findings or evidence-based practices, and a confusion of implementation methods and goals and incomplete plans for implementation. In the USA and some other countries, systems level policies are beginning to support only those few interventions that currently have built up evidence through many RCTs. As this review suggests, PR has many more interventions based on rigorous, but non-RCT studies than RCTs, due in part to the relatively low incidence of the population coupled with the multidimensional, ecological factors

in work, have significantly lower employment rates (Lehman et al., 2002) and about one third of those who enter supported employment programmes are unsuccessful finding competitive work ( Drake & Bond, 2008). Campbell et al. (2009) concede that reaching out to those who are currently unengaged in the world of work or who do not express a vocational goal requires further development of IPS. On balance, given the promising practices available as options that do address the unengaged (e.g. clubhouses, social firms) and the strength of the evidence for IPS, rehabilitation systems should include as large a range of vocational support models as possible to avoid the single model trap (Kramer, Anthony, Rogers, & Kennard, 2003). Supported housing provides people with the possibility of living in the type of residences they prefer in the normal housing market, with flexible support from a provider or helper of some kind that comes into the home anywhere from 4 to 25 or more hours per week as needed and wanted (Anthony et al., 2002). Supported housing can improve the living situation of individuals who are psychiatrically disabled, homeless (Shern et al., 2000) and with substance abuse problems (Padgett, Gulcur, & Tsemberis, 2006). Results show that supported housing can help people stay in apartments or homes up to about 80% of the time over an extended period ( Tsemberis, Gulcur, & Nakae, 2004). In a systematic review of experimental and quasi experimental studies, Rogers, Cash, and Olschewski (2008) conclude that the evidence for supported housing is robust, demonstrating that elements such as rapid entry into housing with options to choose from, combined with intensive case management services and having access to affordable housing with a well integrated service system, lead to better tenure and functional outcomes. Supported education for individuals with severe mental illnesses, pioneered by the Center for Psychiatric Rehabilitation (Anthony & Unger, 1991; Hutchinson, Kohn, & Unger, 1989), provides the services necessary to help individuals access and complete integrated post-secondary educational programmes, rather than segregated or specialized settings, so that they can achieve their educational goals. Rogers, Cash-MacDonald, Brucker, and Maru (2009) comment, in their systematic review of supported education research, that there are very few well-controlled studies of supported education (e.g. Collins, Bybee, & Mowbray, 1998; Mowbray, Collins, & Bybee, 1999). Evidence from existing studies suggests that individuals with significant psychiatric disabilities can enrol in and pursue educational opportunities in integrated settings in the community, such as high schools, community colleges, universities or apprenticeship training

Psychiatric rehabilitation interventions: A review inherent in PR (Farkas & Rogers, 2007). While RCT evidence must be included, both the state of our current knowledge base and the need to transform service delivery require that the PR field consider not only the evidence for a particular practice but also the value base associated with it, in order to create a system congruent with the overall mission of recovery (Farkas & Anthony, 2006). As interventions leave the realm of science and begin to influence national policy and the politics of service delivery, it is important to be wary about overreliance on evidence-based practices which can lead to a single model service system or the exclusion of meaningful promising practices. Brown, Brown, and Sharma (2005) emphasize that it is the value base of an intervention and the perceived quality of life impacted by an intervention that, in the final analysis provides a better measure of the overall merit of an intervention to the individual. Best practices which can transform a service system can be defined as those practices that have a recovery value base (i.e. person orientation, self-determination, partnership, hope) and the best available evidence with it, which may or may not be RCTs. Some evidence-based practices reviewed in this article can be used within the choose-get-keep PR framework, with the few caveats discussed in the article (e.g. supported housing, supported employment); some require modifications (e.g. social skills training, ACT ) to enhance congruence with recovery orientated values to create a rehabilitation best practice. Some promising practices and current value-based interventions, important to PR practice and perceived as meaningful at the patient and family level (e.g. supported education, peer support), require more research to establish a greater evidence base. An effort to incorporate PR at this stage of the fields development requires the use of an array of those interventions with the best available evidence and the most congruent with recovery orientated PR values, rather than simply those with the most RCTs. Implementing best practice in PR is a difficult endeavour. Barriers to effective implementation or knowledge translation include problems such as a confusion of methods and goals, for example, which can lead to using methods designed to increase awareness and understanding of information even though the goal is a change in practice, for example (Farkas, Jette, Tennstedt, Haley, & Quinn, 2003; Sudsawad, 2007). These commonly thought of exposure methods (i.e. getting the word out through journal publishing or systematic reviews leading to practice guidelines), have little or no effect in practice (Shojania & Grimshaw, 2005). Furthermore, adopting quality assurance or improvement methods which only report on behaviour have

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produced only modest results (Drake, Bond, & Essock, 2009a). Introducing PR interventions with the goal of a change in provider practice or behaviour require methods that take into account the complexity inherent in changing behaviour over time. Such expertise and embedding methods focus on systematic training of both providers and supervisors, follow-up supervision of the application of the newly acquired knowledge and skills, as well as changes in organizational structure over time, in order to incorporate behaviour change into daily practice (Farkas et al., 2003; Farkas & Anthony, 2007). Disappointing results in implementing innovations across many countries in the past have also resulted from inadequate implementation plans. Inadequate implementation plans included a lack of clarity about the interventions themselves; a lack of stakeholder support; staffing issues and leadership issues that led to incomplete use of the innovation in practice, inadequate funding and inadequate cooperation among different services (e.g. Backer, Liberman, & Kuehnel, 1986; Corbiere, Bond, Glodner, & Ptasinski, 2005; Farkas et al., 2003; McFarlane et al., 2001; van Erp et al., 2007). In distilling the experience of three decades of PR dissemination in various countries across all continents excepts Africa, the Center for Psychiatric Rehabilitation has identified three main categories of focus important to ensuring a comprehensive implementation plan for introducing PR interventions: culture, commitment, and capacity (Farkas, Ashcraft, & Anthony, 2008). Organizing an implementation plan that assesses and then enhances culture involves ensuring that the organizational structures and ways of doing business are consistent with the spirit and intent of PR and each of the recovery orientated values inherent in its mission, to support the use of the intervention being implemented. For example, user involvement in designing, delivering and evaluating services is critical component of a recovery orientated service culture like PR (Farkas et al., 2005). Promoting the hiring of individuals with serious mental illnesses as peer providers as well as in the role of helping professionals and administrators reflects a culture of full partnership. Simple activities such as celebrating personal successes or inviting peers who have completed university degrees, have families or hold jobs, to speak to staff and patients of an agency for example, can enhance an organizations culture of hopefulness. Culture also includes elements related to the introduction of change (e.g. the extent to which an organization is characterized by openness to learning, willingness to entertain challenges and effective problem solving) (Farkas, 1984, 1990). An organizational culture of openness to innovation and

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M. Farkas & W A. Anthony . emerging methods. These can be tied together by skilled practitioners practising within a process framework of choosing-getting-keeping valued roles. When implemented using comprehensive expertise and embedding methods that pay attention to the culture, commitment and capacity of organizations, such interventions can help individuals with the lived experience of serious mental illness achieve success and satisfaction in the student, worker, resident, social roles they want and thus contribute to the individuals overall recovery.

learning provides positive energy for change that increases the likelihood of implementation success (Farkas, 1990; Whitley, Gingerich, Lutz, & Mueser, 2009). Commitment involves ensuring that all major actors are willing and able to support the implementation efforts. Since such efforts typically take from 3 to 5 years or more to embed into daily practice (Anthony et al., 2002), it is vital that the leaders are not only enthusiastic at the beginning but remain fully committed. Difficulties in stakeholder support (e.g. families, individuals with lived experience, legislators, funding bodies) often reflect inadequate attention being paid to these groups when introducing and embedding innovations. Commitment begins with dissatisfaction with the status quo, a belief in the degree to which resources will exist to make the change, and a basic level of understanding about the characteristics and implications of the PR interventions the organization proposes to implement (Farkas et al., 2008). Effective PR implementation requires ensuring the alignment of commitment among leadership of the critical stakeholder groups so that financial, political and community support work in concert to ensure implementation of the best practice ( Drake et al., 2009a). Capacity reflects aspects of implementation related to staff knowledge, attitudes and skill in delivering the PR best practice. The Center for Psychiatric Rehabilitation has developed competency-based PR training programmes for providers, in specific choose-get-keep skills that can enhance the capacity of providers to deliver many of the psychosocial interventions reviewed. While these interventions and models currently provide training in the delivery of their own process and techniques, discrete practitioner competencies to put the techniques into practice are often missing. Practitioners skills that can be taught and implemented in the delivery of the reviewed interventions include for example, how to assess and develop readiness for change (Farkas et al., 2000a), how to help people determine the valued roles they want (Cohen et al., 1991); how to assess skills and supports relative to the persons valued role aspirations (Cohen, Farkas, & Cohen, 1986); how to teach or modify structured skill programmes to reflect individual needs and how to promote skill generalization (Cohen et al., 1985b), among many others. Research reviews indicate that these skills can be reliably taught and show promise in their use across a wide variety of psychosocial programme models and interventions (Rogers et al., 2006). In conclusion, psychiatric rehabilitation has come of age. There are now robust evidence-based interventions, promising practices and

Declaration of interest: This article was supported in part by the National Institute of Disability and Rehabilitation Research, and the Substance Abuse, Mental Health Administration/Center for Mental Health Services, grant number H133B090014. The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.

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