What’s the equivalent of a wheelchair for a person with schizophrenia? How psychiatric rehabilitation brings community into care

Including employment support in psychiatric care can improve quality of life. Maskot/Getty Images Imagine your dream is to get a job at the local library. You have a love for people and for books. You also have schizophrenia, a psychiatric disability that makes life in the community more challenging. You often have extreme psychological experiences. When you leave your apartment, you hear voices that tell you it’s not safe, and you feel scared. People seem to keep their distance from you. You feel lonely sometimes. Most of the people you spend time with are mental health staff members, who provide medications and psychological therapies to make the voices and paranoia less intense. Their treatment philosophy is based on the belief that by reducing the symptoms, working at the library might be possible for you someday. But what if they have it backward? What if waiting for your symptoms to get better means waiting too long, or even forever? That’s where the concept of psychiatric rehabilitation, or PSR, turns traditional mental health treatment on its head. While PSR does not minimize the significance of psychiatric symptoms, reducing those symptoms is seen as neither necessary nor sufficient for improving quality of life. Instead of asking “What are your symptoms?” and “How can we make them better?” providers instead ask, “What do you want to do?” and “What’s getting in the way?” These questions might lead to interventions that are not traditionally considered mental health services: practicing job interviews, scheduling wake-up calls, learning unfamiliar bus routes or making environmental changes like negotiating accommodations. Irrespective of symptoms, such interventions can support people diagnosed with psychiatric disabilities like schizophrenia, major depression and bipolar disorder. We are psychologists and researchers who have worked in these settings and who study ways to support people with psychiatric disabilities like schizophrenia. And we believe rehabilitative approaches to psychiatric disabilities can help people engage in activities they value, including work, relationships, passions and public service. Origins of psychiatric rehabilitation Psychiatric rehabilitation originated at a time of upheaval and hope. In 1963, President John F. Kennedy signed the Community Mental Health Act into law, establishing mental health centers in the community with the goal of decreasing the number of people living in long-term psychiatric institutions. By 1975, the number of patients in state and county mental hospitals had rapidly declined by 62%. However, the law never really fulfilled its promise. Even when connected to outpatient care, people with psychiatric disabilities had unmet needs related to community living, including educational attainment, employment, housing and community participation, leading to a lower quality of life. But what if building a meaningful and self-directed life in the community really was possible, if people were given the right support? Psychiatric rehabilitation emerged during the 1970s and 1980s in part as a response to the deinstitutionalization movement, where more and more people with psychiatric disabilities lived in the community. Psychologist William Anthony, a pioneer of psychiatric rehabilitation, described the purpose and values of this approach as analogous to physical rehabilitation. Both are centered on improving patients’ ability to live within their chosen environment. For example, in physical rehabilitation, a person with a serious mobility impairment would not only receive treatment that improves their ability to walk on their own, but also supervised practice using a wheelchair. Modifying their environment, such as adding curb cuts to public sidewalks, is also critical. Psychiatric rehabilitation challenges mental health professionals to consider questions like “What is the equivalent of a wheelchair or curb cut for a person with schizophrenia?” One key example of this approach is a form of supported employment called individual placement and support. In this model, employment specialists learn from patients about their goals and preferences; help them search for jobs and identify potential employers; and assist with applications, resumes and interview preparation. Staff will systematically visit businesses in the community to learn about their needs and hiring preferences. Research has shown that this model effectively increases competitive employment for people with psychiatric disabilities, and that most who become employed have a better quality of life. In addition to gaining employment, psychiatric rehabilitation can help people with severe psychiatric disabilities reduce hospital admissions, obtain housing, improve cognitive function and reduce stigma. Each of these interventions is designed to improve a person’s functioning in the community, either by modifying their skills or their environment. Because many of these services can be delivered by people without advanced degrees, psychiatric rehabilitation also opens careers in mental health services to a broader swath of the community. The future of psychiatric rehabilitation Despite its effectiveness, many factors limit access to psychiatric rehabilitation, including underfunding, lack of appropriate Medicaid reimbursement, an unprepared workforce and an overemphasis on pharmaceutical treatment.
Psychiatric rehabilitation practices could improve the extent to which they are culturally tailored and centered on serving the most vulnerable and disenfranchised populations. For example, research has found that having a low income is correlated with worse outcomes in these services, and that not enough programs consider cultural diversity. Progress in treating mental illness has been elusive, and it’s not because researchers don’t know which treatments are effective. Rather, it’s because care quality varies greatly and the best services are often inaccessible. Psychiatric rehabilitation relies primarily on financing through state mental health agencies and Medicaid, and its future depends on sustainable financing. Until investments match need, disparities in the health and quality of life of people living with psychiatric disabilities will continue.

In community, with support Just like those recovering from a physical illness, we believe people recovering from psychiatric disabilities are deserving of comprehensive rehabilitation services that enable their full participation in community life. So imagine once more that you love books, love the library and live with schizophrenia. You got confirmation from your employment specialist that she found a library in the community seeking a part-time worker. She mentioned you to them, and they’re willing to give you a chance. You and your peer support specialist take the bus back and forth to the library one more time to make sure you’re confident about the route. To prepare for your interview, you sit in your community mental health center’s computer lab and use a virtual reality program to practice your job interview skills. Later that afternoon, you share your excitement and fears with peers in a Hearing Voices Network support group. Tomorrow’s your interview. With your support network at your back, you believe your dream could come true.

Adrienne Lapidos's research work is funded by the CareQuest Foundation, the Michigan Department of Health and Human Services, and the National Institutes of Health. She is Associate Editor of Psychiatric Rehabilitation Journal. Elizabeth Thomas receives funding from the National Institute on Disability, Independent Living, and Rehabilitation Research and the Substance Abuse and Mental Health Services Administration. She is Associate Editor of Psychiatric Rehabilitation Journal. Kristen Abraham has received funding from the National Institutes of Health, the Veterans Health Administration and the Michigan Disability Rights Coalition. She maintains an appointment at the Veterans Health Administration Serious Mental Illness Treatment Resource and Evaluation Center and is Editor of Psychiatric Rehabilitation Journal.