Introduction

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:

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).

Introduction

Part 3 of the book describes the main components of the ‘whole system’ mental health rehabilitation care pathway referred to in Chapter 2, ‘What is psychiatric rehabilitation?’ Patients with complex mental health needs are usually referred to rehabilitation services from acute in-patient services and secure services. They may move through a series of treatment and support environments over a number of years, with each stage providing the opportunity for them to gain the confidence and skills to manage their lives with greater independence and autonomy, building on their progress and recovery incrementally. The pathway is shown in summary in Fig. 16.1. It includes a range of in-patient mental health rehabilitation units, some of which may actually be based in a community setting rather than a hospital (see Chapter 17, ‘Rehabilitation in hospital settings’), a range of supported accommodation services (see Chapter 19, ‘Housing: a place to live’), vocational rehabilitation services (see Chapter 20, ‘Work and employment’) and peer support services (see Chapter 21, ‘Peer support in mental health services’). Once out of hospital, individuals are also supported by primary care and statutory community mental health services, including community rehabilitation teams and assertive outreach teams (see Chapter 18, ‘Community-based rehabilitation and recovery’).

Providing a flexible pathway

The exact configuration of in-patient rehabilitation services varies in different localities according to morbidity and need, with inner-city areas tending to require more high-dependency in-patient rehabilitation units, from where service users generally move on to a community-based rehabilitation unit in preparation for more independent, but supported, community living. Most (67%) people who require in-patient rehabilitation, whether delivered in a hospital or in a community-based unit, are able to move on successfully to some form of supported accommodation within 3 years (Killaspy & Zis, 2013).

Community rehabilitation services work closely with supportedaccommodation services to provide comprehensive support to service users as they continue their recovery in the community. When service users are able to manage with less support they move on to less-supported accommodation.

This book aims to provide a comprehensive account of contemporary practice within psychiatric rehabilitation services and indeed beyond mental health services that have a specific rehabilitation badge. As the second edition of a book first published in 2006, it is a celebration of significant progress in the specialty of rehabilitation and in our broader understanding of how people experiencing severe mental health problems can be supported (or not) in their personal recovery journeys. It is also a celebration of diversity: our authors come from diverse backgrounds and use a wide range of theoretical and practical approaches in their work. Throughout you will read a range of terms to describe the people with whom the services work: ‘patients’, ‘clients’, ‘service users’ (the most popular term), ‘sufferers’ and ‘experts by experience’ are all used by different authors in different contexts. What unites our authors is a passion to support service users in recovering a sense of agency, to allow them to get back control over their lives.

There is no ‘magic bullet’ in rehabilitation practice akin to an antibiotic used early in the course of a bacterial infection. Inevitably, practitioners need to be pragmatic and eclectic in their day-to-day work. This pragmatism rightly involves of being aware of the evidence base, but, given the limitations, conflicts and complexities surrounding that evidence base, rehabilitation practice must also reflect the values of the practitioner and others, notably the service user (Adshead, 2009). Values-based practice is a dynamic process that requires constant reflection – it is a toolkit that can be used to guide decision-making rather than a set of rigid, protocolised rules (Woodbridge & Fulford, 2004; Fulford, 2009). Mental health practice continually presents situations where values conflict – the most obvious example being the use of compulsion to deprive people of their liberty and treat them against their will. More subtle is when the rehabilitation practitioner seeks to improve a person's functional skills or personal hygiene in the face of indifference or even hostility. Practitioners can at times be guilty of not seeing the wood for the trees as they concentrate on eliminating symptoms at the expense of a person's desire to live as good a life as possible on his or her own terms.

Introduction

This chapter provides an account of the work of community mental health teams that aim to promote the rehabilitation and recovery of the people they are serving. Both rehabilitation and recovery are ‘everyone's business’ and the principles and practices discussed in the chapter are relevant to all community mental health services. The roles of specialised teams offering assertive outreach, early intervention in psychosis and, in particular, community rehabilitation are, however, described in some detail.

It is important at the outset to emphasise three issues that are often overlooked. First, services are not in themselves treatments – they are, rather, vehicles for delivering treatment and care. Second, a vital element of good treatment and care is the therapeutic relationship between those providing services (the individual practitioner, the treatment team and the wider care system) and the person receiving services (the patient, client or service user) and her or his support network. Third, high-quality work within rehabilitation and recovery almost invariably takes place in the context of effective team working. Effective teams are supportive of the practitioner, have a positive therapeutic culture, reflect on their work and make use of the skills and experience of all team members.

Principles

Rehabilitation services must strive to ensure they work collaboratively and in a recovery-focused, person-centred way. The key aims are to support service users in attaining their goals and moving towards selfmanagement of their mental health condition, while ensuring that the challenges they face are adequately addressed. These challenges include risks such as social isolation, self-neglect, relapse into acute illness, challenging behaviours, comorbid substance misuse, inability to cope, exploitation in the community and co-occurring physical health problems (Kalidindi et al, 2012). To put the laudable aims of rehabilitation services into practice, effective engagement, assessment, formulation and care planning are essential.

Involvement of family, carers and others in the social network of the service user is likely to be important in bringing about sustained positive change. Families need information, advice and support from statutory services and, sometimes, specific interventions such as family work or therapy (see Chapter 10, ‘Family interventions’).

Up to this point this book has provided a review of the concepts surrounding rehabilitation and recovery in mental health services (in Part 1, ‘Setting the scene’), described a range of therapeutic approaches that are important in rehabilitation practice (in Part 2, ‘Treatment approaches’) and set out the core components of an effective and comprehensive rehabilitation service (in Part 3, ‘Key elements of a rehabilitation service’).

All the contributors to Parts 1, 2 and 3 work in the UK, the majority as practitioners working in the National Health Service (NHS) or in academic positions. It is likely that any further edition of this or a future book with similar aspirations would include significantly more contributions from people working in independent and voluntary sector organisations and people with lived experience of severe mental illness.

Rightly, the focus of the book has been on people living with a diagnosis of major mental disorder – schizophrenia, schizoaffective disorder and bipolar disorder – since these diagnoses are by far the commonest among people in contact with specialist psychiatric rehabilitation services. However, an increasing minority of service users have other diagnoses, either as the primary problem or as a comorbidity. Chapter 12, ‘Working with coexisting substance misuse’, is new to this edition. Substance misuse is a common problem for rehabilitation services and their client group, and the topic's omission from the first edition has been rectified. Chapter 11, ‘Working with challenging behaviour’, draws on clinical experience of work in secure settings with people with borderline personality disorder.

Editors inevitably have to make decisions about what goes into a book but equally determine what is left out, either deliberately or by default. Our first edition included a brief chapter on the social context of mental illness, which discussed social factors implicated in the causation of schizophrenia, notably the experience of migration, and the social consequences of severe mental illness, including stigma and impaired self-image. Subsequent research has focused on other forms of psychosocial stress as possible causative factors for psychosis (Morgan et al, 2008; van Winkel et al, 2008), with, as noted in Chapter 5, ‘Understanding madness’, great interest in childhood trauma as a risk factor for schizophrenia in later life (Bebbington et al, 2011).

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).

Introduction

In this part of the book the next eight chapters discuss approaches to treatment in rehabilitation practice. What does treatment mean for people with longer-term psychoses who find themselves in rehabilitation settings? The challenge is great, but the rewards greater. All our authors underline the key importance of forming good therapeutic relationships. An overwhelming sense of hope, despite the challenges, comes through strongly in all the contributions, as our authors answer the question posed. Together, they provide the reader with a formidable array of therapeutic approaches.

This group of people experience complex, multiple and severe issues that affect their ability to live safely and independently in the community. Good treatment necessitates addressing needs by using interventions that are informed by the best evidence. A longer period of engagement may be required than is usual just to facilitate access, and treatments may need to be used particularly creatively and flexibly. The ability to build up a trusting and compassionate working relationship and ensure person-centred practice is central to success. This requires supporting service users to identify their strengths, their resources and their goals. It is necessary to work alongside them, their families and key people in other services to enable holistic, incremental, ‘long-view’ care and progress. The ‘whole system’ approach advocated throughout this book seeks to use everyone within the extended team, working towards common goals alongside the service user. The aim is increasing self-management of the service user's condition(s) and greater independence, with occasional setbacks being understood to be par for the course and an opportunity for learning.

To expand further on the ‘person-centred’ premise, this is about meeting people at whatever point they are on their journey, engaging them, endeavouring to understand them and formulating with them and their significant others an individualised, bespoke or tailor-made plan. Having knowledge of a person's narrative, maintaining continuity and ensuring that necessary support is not taken away before the person is ready are all important. The authors in Part 2 uniformly emphasise the importance of treatment as ‘working with’ people as agents in their recovery rather than merely ‘doing to’ a passive recipient of care.