People requiring rehabilitative interventions are first and foremost individuals, who are likely to have had difficult experiences in their lives, both before and since the emergence of their mental health condition(s). They are likely to have been in contact with services for some years. By the time of referral for rehabilitation they may feel a loss of hope, having seen several clinicians and having received many interventions, none of which have been adequately effective.
The guideline on schizophrenia produced by the National Institute for Health and Care Excellence (NICE) begins with a statement about optimism:
Work in partnership with people with schizophrenia and their carers. Offer help, treatment and care in an atmosphere of hope and optimism. Take time to build supportive and empathic relationships as an essential part of care. (NICE, 2014)
These sentiments are central to our approach to working with service users, work that starts during the assessment process.
It is important to recognise that clinicians hold a position of relative power when they meet with an often disempowered person, sometimes unwilling and often anxious, to consider the current position, how it has been arrived at and to propose a way forward. Starting at the first meeting, an empathic effort is crucial to understand clients and their story, to engage with them as people who have, or can be supported to have, goals, aspirations, strengths and resources. Alongside this, it is important to assess the complex mix of mental health conditions, comorbidities and behavioural needs that they experience, taking a truly biopsychosocial approach.
There is a clear role for personal self-assessment, to ascertain what the service users make of their condition and situation and how and what they would envisage as being of use to them from clinicians and services more generally. Different frameworks can be adopted: service users at the South London and Maudsley NHS Foundation Trust are encouraged to use the Recovery and Support Plan, which is discussed in more detail in Chapter 8, ‘Rehabilitation at the coalface’. This approach resonates with Copeland's Wellness Recovery Action Plan (Copeland, 2002).