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Psychiatric rehabilitation: an empowerment-based approach to mental health services.


As services to people with serious mental illness have moved to the community over the past 40 years, social workers have expanded their roles in the field of mental health (Vourlekis, Edinburg, & Knee, 1998). Social workers are now the major providers of mental health services in the United States (Substance Abuse and Mental Health Services Administration [SAMHSA], 1999). More social workers are employed by community support programs for people with mental illness than any other profession (Rapp, Shera, & Kisthardt, 1993).

At the same time, advances in research-based knowledge about serious mental illness have resulted in improved and radically different treatment models (Nathan & Gorman, 1998). Research on the brain has provided better knowledge of the symptoms and characteristics of psychiatric disorders, allowing for more accurate diagnosis. New psychotropic drugs provide better symptom control without the devastating side effects of previous medications. With better control of symptoms, people with serious mental illness are able to participate fully in life--as workers, spouses or partners, parents, and community members--and are demanding the services that allow them to do so.

Innovative treatment and vocational programs, designed to promote recovery and using principles of psychiatric rehabilitation, help people with serious mental illness develop meaningful relationships, participate in employment or vocational interests, and live successfully in the community. Social workers must become familiar with recovery-oriented psychiatric rehabilitation principles, because this method is encouraged by funding sources and demanded by consumers. Contemporary social workers, educated with an empowerment perspective, will find recovery-based psychiatric rehabilitation programs consistent with social work values and practice models.

Despite its well-established inclusion in community mental health treatment programs and the extensive involvement of practicing social workers in its early development (Pratt, Gill, Barrett, & Roberts, 1999; Rubin, 1996), psychiatric rehabilitation has received little attention in the discipline-specific social work literature. The only article discussing the interface between social work and psychiatric rehabilitation was published over a decade ago (Peterson, Patrick, & Rissmeyer, 1990). Even at that time, Peterson and colleagues expressed concern that psychiatric rehabilitation had "not been widely articulated in the social work literature" (p. 468). Since then, only a few social work doctoral dissertations and articles use the terminology of psychiatric rehabilitation, and these focus on very specific areas of service. It is important to note that social workers have made strong contributions to the development of research-based knowledge that can be viewed in a psychiatric rehabilitation framework. Among these are Mowbray and colleagues' work on supported education (for example, Mowbray, 1999) and on the life domain of parenting (for example, Mowbray, Schwartz, & Oyserman, 2000); Hogarty, Anderson, and colleagues' long-term work on interdisciplinary research teams on family psychoeducation and skills training in schizophrenia (for example, Hogarty, Anderson, & Reiss, 1991); Test and colleagues' work on assertive community treatment (for example, Test & Stein, 2000); and Solomon and colleagues' work on case management (for example, Solomon & Draine, 1996a, 1996b). However, publications describing this research have appeared primarily in interdisciplinary journals. There is still a significant lack of literature on this topic in peer-reviewed social work journals.

One area of psychiatric rehabilitation-related social work literature that has seen a modest increase since Peterson et al.'s 1990 article is in books, primarily used as texts in social work education. Some examples of psychiatric rehabilitation-related books and book chapters are Moxley's (1997) chapter on clinical social work in psychiatric rehabilitation, which appeared in Brandell's Theory and Practice in Clinical Social Work; several chapters in Williams and Eli's (1998) Advances in Mental Health Research; Rapp's (1998) The Strengths Model: Case Management with People Suffering from Severe and Persistent Mental Illness; and Jackson's (2001) recent use of the clubhouse model to illustrate a wide range of generalist social work values, theory, and skills.

Yet many social workers remain unaware of the language and perspective that shape psychiatric rehabilitation unless their social work education program included specific content. Although social work and psychiatric rehabilitation have evolved in the same contemporary environmental context, social workers may not be fully cognizant of the strengths and employment opportunities in this field.



The contemporary field of psychiatric rehabilitation originated in programs of mental health treatment that began as early as the late 1940s. Many social workers employed in urban community centers, then termed "intermediate care facilities," had been trained in social group work (Rubin, 1996). They used group methods to help individuals newly returned to the community from psychiatric hospitals become more integrated in the community (Rubin, 1996). Social work staff in these programs expressed a clear rehabilitation philosophy, as evidenced in Prager and Tanaka's (1980) description:
 Since its founding seventeen years ago, Hill House
 has held the philosophy that the achievement of
 such rehabilitation goals as developing self-confidence
 and improving self-concept results from
 the client's acquisition of appropriate behavioral
 and instrumental roles. (p. 32)

Staff at these facilities developed programs that focused on the development of social skills often needed by individuals recovering from episodes of serious mental illness. These methods became known as psychosocial rehabilitation, and the efforts by the social work staff contributed to the formation of the International Association of Psychosocial Rehabilitation Services (IAPSRS), an interdisciplinary organization. With the deinstitutionalization of mental health treatment, these programs were positioned to influence mental health services.

Consumers and families provided an additional impetus for improved community services to people with serious mental illness. Consumers returning to the community from psychiatric hospitalization shared their experiences and support on the steps of the New York Public Library, resulting in the organization of Fountain House. Termed a clubhouse, Fountain House was run and controlled by its consumer members but often included the strong support of professional social work staff, among them John Beard, the long-term administrator of Fountain House (Pratt, Gill, Barrett, & Roberts, 1999), and Jerry Dincin, administrator of Chicago's Thresholds program (Dincin & Bowman, 1995). Until the 1970s these consumer-controlled programs existed primarily in large urban areas.

In the early 1970s, the consumer movement gained a national focus. People with various disabilities became aware of their common concerns and found that by meeting they could advocate for more responsive programs and policies. Part of this broad disability rights movement, the then-termed "mental patients" movement, was organized by groups in Portland, Oregon; Vancouver, British Columbia; and New York City from 1970 to 1971 (Emerick, 1989). These groups developed support networks and started a dialogue with providers to advocate for the development of more effective services.

In 1979 the National Alliance for the Mentally Ill (NAMI) was organized by and for families of people with mental illness. NAMI's original goals were to provide education and support to families who often were blamed for their relative's illness by professionals who subscribed to a now-discredited theory of causation. NAMI also developed strong political support for additional research on causation and treatment of the most serious mental illnesses. Both of these consumer initiatives were instrumental in influencing the type of services funded nationwide by the National Institute of Mental Health (NIMH).

In the mid-1970s NIMH piloted the Community Support Program. This program funded community mental health centers to offer outreach, medical, and mental health services to people with serious mental illness living in the community. Psychiatric rehabilitation was a core philosophy of NIMH's Community Support Initiative (Peterson et al., 1990). By the mid-1980s the psychiatric rehabilitation approach was well-established in federal and state mental health services (Peterson et al.), an emphasis that has continued since that time.

A number of educational programs specific to psychiatric rehabilitation exist nationwide. The most widely recognized educational program is housed at the Center for Psychiatric Rehabilitation at Boston University. Since 1978 this program has trained psychiatric rehabilitation professionals at the master's, postmaster's, and doctoral levels. The interdisciplinary membership organization IAPSRS oversees requirements for the Registered Psychiatric Rehabilitation Professional (RPRP) credential and publishes the Psychiatric Rehabilitation Journal. The RPRP designation is available to practitioners who meet its requirements with degrees in a variety of disciplines, including social work.

Guiding Principles

The basic philosophy of psychiatric rehabilitation is to teach people with serious mental illness the skills they need to function as normally as possible in the community. Developed as an alternative to the medical model in which people with mental illness were perennially dependent "patients," its overarching goals are to increase community functioning and reduce the effect of symptoms of the psychiatric disorder. Consumers develop skills to find and keep a job, live in community housing, participate in community recreation, and use social networks in the community for support. A range of social, educational, occupational, behavioral, and cognitive methods are used (Barton, 1999).

Many of these programs include interventions provided by a range of mental health disciplines: skills training by rehabilitation professionals, mental health services by social workers and psychologists, and psychopharmacology by psychiatrists and psychiatric nurses (Cook et al., 1996).

Three major philosophical principles guide psychiatric rehabilitation programs: empowerment, competence, and recovery (Barton, 1999). The principle of empowerment encompasses both personal and community aspects. A focus on personal empowerment encourages consumers to actively manage their psychiatric symptoms, to make choices about the development and implementation of their treatment, and to develop a positive sense of self (Cook et al., 1996). As consumers develop interpersonal skills, they become increasingly interdependent with their social network, and more independent of traditional mental health services (Freund, 1993). The community aspect of empowerment results when individuals develop social support systems, participate in employment programs, and advocate for rights and improved programs. Thus, an empowerment focus profoundly changes the expectation of the consumers' roles, from passive participants in mental health programs to managers of their own lives and collaborators within their social network.

A focus on competence is pervasive in psychiatric rehabilitation programs. Because competence is evaluated through functioning rather than diagnosis, psychiatric rehabilitation programs focus on teaching skills to function successfully in a variety of life domains. This focus on strengths and wellness translates to enhancing talents and skills rather than monitoring symptoms and deviance (Cook et al., 1996). Services presume that consumers can be successful, and interacting with recovering consumers who are functioning well in the community reinforces this goal and expectation.

The concept of recovery is increasingly used by consumers and professionals to describe the desired outcome in serious mental illness (Anthony, 1993). Borrowed from the field of substance abuse, the term "recovery" acknowledges the variable course and remission of symptoms that have been found to occur in even the most serious mental illnesses (Adler et al., 1995). When serious mental illnesses are viewed in a framework that anticipates recovery instead of chronicity, services and attitudes must change to reflect the shift in expected outcomes. For example, Harding, Zubin, and Strauss (1992) reviewed 25 years of research on schizophrenia and found the concept of chronicity to be a poor descriptor of the actual experience. Instead, the authors found heterogeneity among individuals' experiences of schizophrenia, with many having a prolonged course. This finding provides additional evidence that the expectation of recovery or improvement is realistic for many consumers. Consumers can experience improved functioning across life domains, including self-care, social, cognitive, and vocational areas. Instead of focusing efforts on accepting and adjusting to chronic, unremitting disability, consumers focus on realistic hope for improvement and symptom management throughout the life course of the psychiatric condition.

Service Components

Barton (1999) developed a typology to describe the major services components in psychiatric rehabilitation. These components are skills training peer support, vocational services, and consumer community resource development. Skills training is a curriculum-driven psychoeducational approach that teaches consumers practical skills in interpersonal relationships, vocational skills, life skills such as budgeting and parenting, and active management of the symptoms of their psychiatric condition. The emphasis of skills training is on improving functioning across the full range of life domains. Development of the interpersonal skills that allow individuals to relate to others to provide a buffer for stress has been a focus of Liberman's highly structured, behavioral method (Liberman, DeRisi, & Mueser, 1989).

The peer support component emphasizes consumer involvement, leadership, decision making, and socialization experiences. Programs and activities that facilitate the development of social networks and social support include clubhouse programs, advocacy networks, support groups, and other services. These programs seek to normalize the experience of consumers. Consumer involvement goes beyond the client role. Consumers increasingly have taken on provider roles as case managers (Solomon & Draine, 1996a, 1996b) in assertive community treatment (Lyons, Cook, Ruth, Karver, & Slagg, 1996) and in consumer-controlled self-help agencies (Chamberlin, Rogers, & Ellison, 1996). In a psychiatric rehabilitation approach, recovering consumers serving as paraprofessionals or peer counselors provide insights about recovery drawn from their own experiences. They can sensitize their colleagues to issues of stigma and discrimination within the organization and the community and be role models for other consumers (Frese & Davis, 1997; Mowbray et al., 1996).

Vocational service is the third sphere in Barton's (1999) framework and includes programs that train and support consumers in employment settings. The vocational domain receives particular attention in psychiatric rehabilitation because the social status of Americans is often judged by their employment. Those who do not work or are unable to work are stigmatized, so status as a worker can provide protection from the existing stigma of psychiatric disability. Employment and earned income provide an entry to other valued roles, including those of spouse, friend, neighbor, customer, and taxpayer (Carling, 1995).

In contrast with earlier efforts that placed consumers in low-level employment without regard to their interests, newer employment strategies use an individualized approach (Sullivan, Nicolellis, & Danley, 1993) in which the consumer specifies job interests before beginning training. Also, programs known as supported employment provide vocational placement, training, and job coaching so that consumers become workers in a variety of business occupations.

Work is also an important dimension in clubhouse programs (Jackson, 2001). Clubhouses stress the value of work as consumers participate in running the clubhouse and filling services contracts developed between the clubhouse and other businesses. In this transitional employment model, the clubhouse contracts with employers for jobs, which are filled by members of the clubhouse. Transitional employment is a flexible approach in which individuals may work at a job site for a period of time and then may leave for another transitional employment job or for competitive employment. The transitional employment position is then staffed by another clubhouse member, ensuring employers that the position will always be filled. Other models include the operation of a consumer-run business, which provides consumers with entrepreneurial training to enable them to run a competitive business.

The fourth service component in a psychiatric rehabilitation framework is consumer community resource development (Barton, 1999). This domain encompasses a variety of programs that support successful community living. Examples range from family education and support to advocacy efforts and drop-in centers. Supported housing is a crucial resource for people with mental illness who are living in the community and working in vocational programs. This may range from congregate living (that is, group homes) to agency-owned apartment complexes to financial support for apartments in the private sector (Livingston, Srebnik, King, & Gordon, 1992). In agency-owned settings, staff often is housed in the building or complex to provide training, support, and assistance to consumers.

Supported education is another resource for consumers that can assist with training for vocational goals or provide general postsecondary education. Several models have been developed that include self-contained classrooms for teaching literacy and study skills, on-site support at colleges through services for disabled students, and mobile support from staff at community mental health centers (Palmer-Erbs & Unger, 1997). These various supportive programs to develop and maintain community integration are vital in reversing long-established patterns of isolating people with mental illness from society.


Programs designed to promote recovery through psychiatric rehabilitation apply a philosophy consistent with empowerment-based social work practice. A social work empowerment approach works toward obtaining the resources consumers need to reach their goals and gain personal, social, and political power (Lee, 1994). Following Freire's (1973) theory of radical pedagogy, a transformation to critical consciousness occurs when oppressed people explore the connection between personal and political power by discussion with others (Gutierrez, 1994; Simon, 1994). Social workers support the political dialogue and organization that develop when members of oppressed groups, such as consumers of mental health services, meet. The power of naming is supported when social workers acknowledge and affirm the "consumer/ survivor" nomenclature used by present and former consumers. The term is widely acknowledged to indicate the oppression many consumers have experienced in the mental health treatment system (Trainor, Shepherd, & Crawford, 1997). In particular, involuntary hospitalization and involuntary psychotropic medication with burdensome and potentially permanent side effects are identified as oppressive. The term "survivor" indicates that consumers view themselves as surviving the oppression of the treatment system.

Psychiatric rehabilitation programs provide a range of services that enable consumers to live successfully in the community, work in a meaningful vocation, and develop support systems. However, although these programs do an excellent job of teaching skills and providing support, they are less likely to incorporate an empirically based clinical component. Newer, empirically tested psychotherapies have enabled consumers to gain insight into symptom triggers and management and learn more adaptive methods of interpersonal functioning and emotion regulation. Evidence-based interventions such as Linehan's (1993) dialectical behavior therapy have been adapted to work with a variety of personality and mental disorders. Cognitive-behavioral approaches have received empirical support for use with major depression, bipolar disorder, and schizophrenia (Nathan & Gorman, 1998). These clinical interventions should be included in the training of social workers who are planning a career serving people with serious mental illness.

Social workers can provide a range of services in psychiatric rehabilitation programs, including therapeutic, case management, education, and broker roles. However, they need to use their skills in collaboration with other disciplines. Social work education needs to acknowledge the critical importance of interdisciplinary teams in mental health. Social workers should emphasize skills needed to clarify professional roles and boundaries and develop teamwork skills. Well-functioning teams need to be developed and maintained, and there are specific strategies to accomplish each of these functions (Payne, 2000). Interdisciplinary collaboration needs continued delineation, discussion, and skills building for all health professionals, because all too often client services are impaired through the ego conflicts of providers.


Social work education is governed by the accreditation standards of the Council on Social Work Education (CSWE). CSWE mandates a generalist approach to foundation practice at both the bachelor's and master's degree levels, to prepare social workers to intervene across levels of intervention and populations. The cost of this broad focus of foundation professional education may be a decreased opportunity to modify content needed for specific client groups. A recent response to this dilemma is Jackson's (2001) excellent use of the clubhouse model to illustrate generalist practice. Core principles of psychiatric rehabilitation are consistent with foundation social work practice principles, such as the importance of self-determination, social supports, the strengths perspective, empowerment, and advocacy. When teaching these concepts, social work educators can make the translation from social work to psychiatric rehabilitation and thereby emphasize consumerism, coaching, recovery, and social support methods. Foundation students need to be exposed to the hopes and needs of individuals who have psychiatric disorders. Schools of social work and social agencies should consider the use of NAMI's Living with Schizophrenia and Other Mental Illnesses program (2001). In this national program, local consumers have been trained to use videos and discuss their own experiences to inform many audiences. Social work students can meet consumers on a personal level and potentially gain an interest in working in psychiatric rehabilitation programs.

At the advanced master's degree level, students are able to select a concentration in their area of interest. However, practice concentrations in mental health may focus on psychotherapeutic interventions instead of psychiatric rehabilitation. If there is an emphasis on insight-oriented interventions or on interventions without empirical support for effectiveness with people who have serious mental illness, then students are not being well-prepared to work or take leadership roles in this large source of social work employment.

Social work programs must do a better job of teaching students to match their therapeutic interventions to the specific cognitive and emotional needs of clients; to this end, programs must teach interventions appropriate for the large group of people with serious mental illness. This information can now be found in the social work texts and chapters previously mentioned. Psychiatric rehabilitation texts (for example, Pratt et al., 1999) also can be used as adjunct texts in social work courses to ensure that students learn specific content.


Psychiatric rehabilitation is a framework for providing services to people with mental illness that encourages adaptive community functioning in all life domains. This approach is consistent with social work's ecological systems model, which emphasizes the importance of transactions in the environment, social networks, and adaptation. A focus on skills building, successful community experience, social support, and active self-management is emphasized in both social work and psychiatric rehabilitation practice. The empowerment focus of the social work profession is compatible with the orientation of psychiatric rehabilitation programs toward recovery and normative community functioning.

Social work also has much to contribute to psychiatric rehabilitation programs, where therapeutic services can be undeveloped. As direct services providers, social workers can use evidence-based clinical approaches that often are not provided in current programs. As advocates, social workers can use their skills to encourage politicians and social policymakers to adequately fund mental health programs emphasizing empowerment and psychiatric rehabilitation approaches. As team members, social workers can work with other health care providers to offer a seamless and integrated array of services that enable people with mental illness to function successfully in their families and their community. Social work education can contribute to this effort by educating students about psychiatric rehabilitation frameworks, interdisciplinary collaboration, and empirically supported therapeutic modalities that enable people with mental illness to function more successfully than ever before.

In the early 21st century, mental health professionals can draw from a new array of services, theories, and skills that have revolutionized treatment of people with mental illness. Consumers deserve much credit for demanding more relevant and appropriate services and, in the process, inspiring professionals to work in partnership with them. Social workers have an important role to play in this process.


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Layne K. Stromwall, PhD, ACSW, is assistant professor, School of Social Work, College of Public Programs, Arizona State University, P.O. Box 871802, Tempe, AZ 85287-1802; e-mail: Donna Hurdle, PhD, ASCW, is assistant professor, School of Social Work, Arizona State University.

Original manuscript received October 25, 2000 Final revision received October 16, 2001 Accepted November 15, 2001
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Author:Stromwall Layne K.; Hurdle, Donna
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Date:Aug 1, 2003
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