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Identifying psychiatric rehabilitation interventions: an evidence and value based practice.

Psychiatric rehabilitation is a field that is over thirty years old, rooted in the principles of physical rehabilitation, with its own knowledge base, philosophy and interventions (1-3). Rossler's article does an excellent job in reviewing the basic concepts and characteristics of psychiatric rehabilitation and some of the evidence based interventions or program models that have, rightly or wrongly, come to be associated with it. 
 
Value based medicine has emerged as a twin concept to evidence based medicine and acknowledges the importance of the patient's perception of the relevance of an intervention (4). Value based practice for individuals with serious mental illnesses starts with the notion that recovery, or the taking back/ regaining of a meaningful life (1,5), has become not only scientifically possible (6), but also is perceived as the relevant mission for services (6-8). The overall purpose of a psychiatric rehabilitation service, as compared to other types of services, is to contribute to this outcome by enhancing functioning in a role valued by society and selected by the individual (1). The fundamental values of psychiatric rehabilitation, as integral an element of the field of rehabilitation as its evidence base, include the critical importance of empowerment and choice, partnership, hope, a focus on an individual's strengths and interests as well as limitations, and an outcome or results orientation, among several others (3,9). 
 
Whether or not a particular intervention is considered to be a rehabilitation intervention, therefore, is not defined by the simple fact that it focuses on skills or supports for individuals with serious mental illnesses. It is defined rather by its contribution to the primary outcome of enhanced functioning in a valued role and the congruence of the value base of the intervention itself. Is the person more able to be successful and satisfied as a mother, tenant, landlord, lawyer, janitor or student as a result of the intervention offered? Or is the intervention effective only at improving grooming skills? Is grooming the critical skill to become a student? Is skills training used to manage symptoms? It has long been clear that there is only a weak correlation between symptoms and role functioning (1,10,11): improving symptom management, while critically important to treatment outcomes, is not, therefore, a rehabilitation intervention. Those case management interventions that are effective in preventing rehospitalization and maintaining stability, but not in achieving a valued role, are also not rehabilitation interventions. 
 
Equally, practices that include effective interventions not congruent with the value base of rehabilitation are not, strictly speaking, psychiatric rehabilitation. Interventions that are imposed on individuals, as Rossler points out, are not consistent with rehabilitation. Individuals cannot be subtly coerced into participating in rehabilitation. Engaging individuals depends upon their current state of readiness to begin thinking about a valued role (9). Readiness can be developed, if the individuals are interested but not ready (6,7). Interventions not focused on an individual's choice of role are not consistent with rehabilitation. Interventions that don't assess and build upon the person's strengths and interests are not consistent with rehabilitation. Choice, partnership and hope can be facilitated through processes such as values clarification, problem solving processes and a myriad of other techniques designed to help an individual use his/her strengths and interests to choose, get and keep his/her valued role. 
 
This process can be used in any effective program model (e.g., supported employment) (13) and has been demonstrated to be successful even for the most disabled individuals (1,14,15). 
 
In order to maximize the multidimensional process of recovery, access to a wide array of services is recommended, if services are used at all (8,16). This requires that psychiatrists be clear about the expected contributions and outcomes of each, to avoid confusion and unmet expectations due to inaccurate labeling of services. Psychiatric rehabilitation services should be those which are effective in facilitating success and satisfaction in valued roles through a process clearly congruent with accepted rehabilitation values.