Introduction

The ‘coalface’ for the chapter authors comes from working in mental health rehabilitation services (in-patient and community) in the UK National Health Service. This involves working with service users with complex clinical presentations – more than half have more than one significant psychiatric diagnosis. This clinical context is further complicated by: behaviours risking harm to self, to others and from others; relatively greater physical health problems, resulting in an excess mortality of up to three times that of the general population (Laursen et al, 2007); and working with complex social factors, such as current adversity, social isolation and stigma.

In this chapter, practical ways in which to help service users improve their functional skills are shared. The term ‘functional skills’ is commonplace in rehabilitation settings. ‘Functional skills’ are defined by the concept of need. Needs-assessment approaches aim to identify need across a range of domains. Need can arise from the service user struggling in a given domain of functioning (Brewin et al, 1987; Slade et al, 1999). Therefore, identified need can indicate that intervention is required by rehabilitation clinicians to support the person improving ‘functional skills’. Box 8.1 summarises the skills areas with which rehabilitation clinicians are frequently working, and is based on the needs-assessment literature.

This straightforward definition of functioning in relation to identified needs is, though, an oversimplification. Slade et al (1999) suggest that what is identified as a need depends on whose viewpoint is considered: service user, carer or clinician. They may concur, or there may be differing perspectives. The recovery approach recognises that what is most meaningful to the service user should shape the agenda (Slade, 2009). Brewin et al (1987) make a distinction in assessing functioning between lack of competence (the skill has been lost or not acquired) and lack of performance (the skill's performance is affected by psychological factors such as motivation, negative affect or lack of opportunity to perform).