Rehabilitation Psychiatry

Rehabilitation psychiatry is “A whole systems approach to recovery from mental illness that maximises an individual’s quality of life and social inclusion by encouraging their skills, promoting independence and autonomy in order to give them hope for the future and leading to successful community living through appropriate support“. (here) This definition is the opening statement on the Faculty of Rehabilitation and Social Psychiatry home page (here), a part of the Royal College of Psychiatrists. Unfortunately, psychiatric rehabilitation has little overlap with any other rehabilitation, at least in the UK. This separation is in keeping with all the different separated services – cardiac, pulmonary, visual. auditory, paediatric, orthogeriatric etc. It illustrates, starkly, how there is no Rehabilitation Community in the UK. Yet, on reading the psychiatric rehabilitation research literature, the commonalities are apparent.

Context

Psychiatry has been a separate medical specialisation started. This separation can probably be traced back to Descartes, and his hypothesis, in about 1650, that mind and body were separate entities. This dualistic philosophy is still powerful. After neurology became established towards the end of the nineteenth century, psychiatrists such as Sigmund Freud (originally a neurologist) separated from neurology. Few countries took up the speciality of neuropsychiatry.

Also, in the second half of the nineteenth century, the Victorians built large asylums to accommodate ‘the insane’. In practice, people incarcerated were socially deviant, for example, having children outside or before marriage.

This early separation of mental health services from other healthcare was characterisedrised by complete separation geographically, financially, and organisationally. The foundation of the NHS perpetuated the split, and Social Services incorporated the break into its structures, with separate mental health and physical disability services.

Rehabilitation for people with disordered mental health started in the mid-nineteenth century with ‘moral therapy’, which emphasised the importance of work, leisure, and social activities. (here) In the first half of the twentieth century, vocational rehabilitation became the predominant rehabilitation focus, possibly related to service members suffering from the psychic horrors of war. From the 1950s onwards, deinstitutionalisation and community management became a significant focus, and rehabilitation concerned itself with re-establishing people in the community. More recently, rehabilitation included psychosocial rehabilitation and the teaching of skills.

The biopsychosocial model of illness arose from psychiatry, and psychiatry has been familiar with the model since its inception. Nonetheless, psychiatry is also framed in a biomedical model, attributing mental illnesses to ‘chemical imbalances in the brain’.

The history of rehabilitation psychiatry differs from most other rehabilitation. Whereas war injuries were the initial driving force behind non-psychiatric rehabilitation, difficulties within civilian society drove psychiatric rehabilitation. The psychological consequences of war were recognised and taken on during the First World War. Craiglockhart hospital is one well-known example where, in its brief 28-month existence, it pioneered psychiatric rehabilitation for the consequences of war. (here) Nevertheless, psychiatric rehabilitation has had a much closer link to the effects on a person living in a civil society with its cultural rules, financial constraints, and many other stresses.

Rehabilitation psychiatry brings an interestingly different focus to rehabilitation. It highlights the social aspect of all rehabilitation and that rehabilitation is not restricted to sudden-onset conditions. Most patients receiving psychiatric rehabilitation will have had a gradual onset of problems, and many will need a level of long-term support.

Medical training

Any doctor training in adult psychiatry can choose the “General Psychiatry with endorsement in Rehabilitation Psychiatry Specialty Training” curriculum. (here) Trainee psychiatrists can enter this branch of psychiatry after a three-year core training in psychiatry. The programme includes two years of general training and one year of rehabilitation psychiatry training.

I was unable to find any high-level training outcome in the curriculum that mentions rehabilitation specifically. The only descriptors were:

• “Provide comprehensive adapted rehabilitation programmes for service users with cognitive deficits associated with severe mental illness/co-morbid conditions.”,
• “Use negotiation and management skills to promote and develop rehabilitation services for patients with severe and enduring mental illness and to develop strategies to tackle adverse commissioning cultures.“,
• “Promote a social psychiatry/recovery culture amongst staff of services delivering rehabilitation”.
• There is no mention of the biopsychosocial model of illness in the curriculum.

I conclude that the explicit training goals in rehabilitation psychiatry as set out in the curriculum concern management and not the rehabilitation process.

Additional information.

Given the relative lack of detail about rehabilitation psychiatry in the curriculum, I will review some publications that discuss and describe it. Thi review draws heavily on the work of Professor Helen Killray from University College Hospital, London (here), who has played a significant role in developing the speciality.

In England, a Trust was and still is the name given to an organisation responsible for providing healthcare services. A Trust may include one or more hospitals and/or community-based services. In 2004 all 75 Mental Health Trusts in England were surveyed about the rehabilitation psychiatry services they provided. Two did not provide any rehabilitation, and eight more did not respond. These Trusts covered 93 boroughs.

The telephone survey asked all respondents from the 93 boroughs to state how they would define rehabilitation. The results were analysed, and “the most common themes identified were: improvements in quality of life and skills despite having a major mental illness; the gaining of hope; the ‘‘recovery’’ model (a positive expectation of improvement and increasing independence); and the use of a whole system, integrated approach. A minority (7%) felt that ‘‘rehabilitation’’ was an outmoded term.” (here)

A detailed list of the concepts used, in order of frequency, was:

• Improving quality of life and wellbeing, and instilling hope
• Maximiing skills
• Aiding recovery
• Achieving greater independence
• Optimising a peron’s potential in the face of illnes
• Giving greater autonomy
• Achieving social inclusion
• Using a whole system approach, integrating services
• Improving functioning
• Giving biopsychosocial treatments
• Having specialised services for people with a high level of need.

Their data and analysis led the authors to propose the definition given in the first paragraph. They noted a difference from previous reports: “This differs from previous definitions of rehabilitation in its lack of focus on disability (Bennett, 1978: ‘‘. . . the process whereby a disabled person is enabled to use their residual abilities to function effectively in as normal a social situation as possible’’; Shepherd, 1995: . . . ‘‘to maximise function whilst at the same time acknowledging the possibility of relatively fixed disabilities and the necessity of providing supportive environments’’).”

A recent editorial (here) has summarised the main approaches used in 2021 for people with complex psychosis:

• delivering “recovery-based rehabilitation”, which basically means working towards some improvement, “based on the belief that it is possible for someone to regain a meaningful life, despite serious mental illness.” (NICE definition, here)
• family and social supports, an approach based on improving family relationships
• integrating complex interventions, which means (in this editorial) focusing on improving function, vocational rehabilitation, and providing supported accommodation
• increasing exercise, avoid sedentary life-style
• managing co-existing substance abuse

Last, a recent scoping review of factors contributing to better outcomes from severe mental illness (here) identified the following key elements:

• supportive relationships were associated with a better outcome. Three types of relationship were important: therapeutic, familial, and with members of the community.
• possessing a sense of meaning was associated with a better outcome. Three facets were extracted from the studies: having a ‘sense of self’, though this was poorly and inconsistently defined, having a sense of hope, but this was also not well defined and included such concepts as spirituality, and having a sense of purpose, which related to undertaking peronally meaningful activities and having higher self-esteem
• participation, which fell into two categories: performing roles that the peron valued, and having a sense of agency, being able to influence his (or her) own life.

This very brief overview suggests many areas of similarity between rehabilitation and other areas of rehabilitation. The differences are in focus, focusing on integrated systems and services and a much greater emphasis on social aspects such a housing, support and interpersonal relationships.

NICE guidance

On 19th August 2020, the National Institute for Health and Care Excellence (NICE) published Rehabilitation for adults with complex psychosis, national guidance (NG181). (here) Its overview states that “It aims to ensure people can have rehabilitation when they need it and promotes a positive approach to long-term recovery. It includes recommendations on organising rehabilitation services, assessment and care planning, delivering programmes and interventions, and meeting people’s physical healthcare needs.“

The guideline sets out some overarching principles of rehabilitation. These refer to people with complex psychosis, which is defined as people with a psychotic illness and at least one other feature from (a) cognitive impairment, (b) other psychiatric disorder such as substance abuse, (c) a neurodevelopmental disorder such as autism spectrum disorder, and (d) physical health disorder (maintaining a dualistic approach to a person’s health).

The principles are (in general terms):

1. be embedded in a local comprehensive healthcare service
2. provide an approach that anticipates some improvement in the patient’s situation and has a shared ethos and agreed goals, a sense of hope and optimism, and aims to reduce stigma
3. deliver individualised, person-centred care through collaboration and shared decision making with service users and their carers involved
4. be offered in the least institutional environment possible and aim to help people progress from more intensive support to greater independence through the rehabilitation pathway
5. recognise that not everyone returns to the same level of independence they had before their illness and may require supported accommodation (such as residential care, supported housing or floating outreach) in the long term.

These principles apply equally to all rehabilitation. They are what I have put forward, less succinctly, in various blog posts and other publications. (here and here)

The remainder of the guideline covers matters that apply directly to all rehabilitation services. The content of this document shows why we need a national community of rehabilitation services acting as a single organisation. I will list the significant headings and subheadings with comments. To see how the guidance could be transposed into all rehabilitation, read it.

The main recommendations are titled:

1. Who should be offered rehabilitation? Answer from NICE: anyone with residual functional limitations after any treatment has been given, regardless of where they are living.
2. Overarching principles. Already reviewed.
3. Organising the rehabilitation pathway. This requires joint working with all other health and non-health agencies, and a lead commissioner for an integrated service, which must cover all transitions across all boundaries.
4. Improving access to rehabilitation. Monitor equity (equal access according to need, no discrimination).
5. Delivering services within the rehabilitation pathway. This includes multi-professional teams, appropiate size of inpatient facilitie to meet need, quality improvement, delivery of rehabilitation in the community, and supported accommodation.
6. ‘Recovery-oriented’ rehabilitation services. This covers supporting people to make decisions, universal staff competencies (as discussed here), maintaining and supporting social networks.
7. Person-centred care through assessment and formulation. (as described here) This includes “a comprehensive biopsychosocial needs assessment by a multidisciplinary team within 4 weeks of entering the rehabilitation service“, care planning and review (goal setting)
8. Rehabilitation programmes and interventions. Covering daily living skills, interpersonal and social skills, community activitie, leisure activities, education and work, and also substance abuse (relevant in all rehabilitation services).
9. Adjustment to (mental health) treatments in rehabilitation. Adjusment of disease-specific treatments will apply in all rehabilitation. The specific treatments will differ according to the disease.
10. Physical healthcare. (This distinction perpertuates the mind-body dualism which is so pernicious in its influence.) All rehabilitation services should consider all aspects of healthcare at all times.

National Rehabilitation Community

Psychiatric rehabilitation services have a great deal to contribute. The fact that NICE guidance focuses on service design, structure and commissioning, with almost no mention of specific interventions, contrasts with the reluctance of NICE guidance on stroke or multiple sclerosis (for example) even to consider these matters. The attention given to social aspects of rehabilitation is also much more significant than in many other rehabilitation services.

In return, other rehabilitation services and organisations may have much to offer psychiatric rehabilitation. For example, research in many fields of rehabilitation is well-advanced and has developed methods and skills that could be used in research into rehabilitation psychiatry.

The understanding and conceptualisation of rehabilitation would be advanced considerably through discussions across all branches of rehabilitation. I have not read much about psychiatric rehabilitation, though I have read two textbooks published in the 1980s. Researching for this page has given me new insights. I hope that discussing all aspects of rehabilitation will enhance everyone’s understanding. Rehabilitation psychiatry would be an essential contributor to the synthesis.