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Psychiatric rehabilitation today: an overview

Department of General and Social Psychiatry, University of Zurich, Militrstr. 8, CH-8021 Zurich, Switzerland

All patients suffering from severe and persistent mental illness require rehabilitation. The goal of psychiatric rehabilitation is to help dis-
abled individuals to develop the emotional, social and intellectual skills needed to live, learn and work in the community with the least
amount of professional support. The overall philosophy of psychiatric rehabilitation comprises two intervention strategies. The first strat-
egy is individual-centered and aims at developing the patients skills in interacting with a stressful environment. The second strategy is
ecological and directed towards developing environmental resources to reduce potential stressors. Most disabled persons need a combi-
nation of both approaches. The refinement of psychiatric rehabilitation has achieved a point where it should be made readily available
for every disabled person.

Key words: Psychiatric rehabilitation, severely mentally ill, sheltered housing, supported employment, case management, assertive
community training

The goal of psychiatric rehabilitation Health (ICF) (4) includes a change from cally mentally ill have the diagnosis of
is to help individuals with persistent and negative descriptions of impairments, schizophrenic disorders, other patient
serious mental illness to develop the disabilities and handicaps to neutral de- groups with psychotic and non-psy-
emotional, social and intellectual skills scriptions of body structure and func- chotic disorders are targeted by psychi-
needed to live, learn and work in the tion, activities and participation. A fur- atric rehabilitation. Today all patients
community with the least amount of ther change has been the inclusion of a suffering from severe mental illness
professional support (1). Although psy- section on environmental factors as part (SMI) require rehabilitation. The core
chiatric rehabilitation does not deny the of the classification. This is in recogni- group is drawn from patients with per-
existence or the impact of mental illness, tion of the importance of the role of en- sistent psychopathology, marked insta-
rehabilitation practice has changed the vironmental factors in either facilitating bility characterized by frequent relapse,
perception of this illness. Enabling per- functioning or creating barriers for peo- and social maladaption (5).
sons with persistent and serious mental ple with disabilities. Environmental fac- There are other definitions currently
illness to live a normal life in the com- tors interact with a given health condi- used to characterize the chronically
munity causes a shift away from a focus tion to create a disability or restore func- mentally ill (6). They all share some
on an illness model towards a model of tioning, depending on whether the en- common elements, i.e. a diagnosis of
functional disability (2). Therefore, oth- vironmental factor is a facilitator or a mental illness, prolonged duration and
er outcome measures apart from clinical barrier. role incapacity.
conditions become relevant. Especially The ICF is a useful tool to compre- Up to 50% of persons with SMI car-
social role functioning including social hend chronically mentally ill in all their ry a concomitant diagnosis of sub-
relationships, work and leisure as well dimensions, including impairments at stance abuse (7). The so-called young
as quality of life and family burden is of the structural or functional level of the adult chronic patients constitute an ad-
major interest for the mentally disabled body, at the person level with respect to ditional category that is diagnostically
individuals living in the community. activity limitations, and at the societal more complicated (8). These patients
level with respect to restrictions of par- present complex patterns of symptoma-
ticipation. Each level encompasses a tology difficult to categorize within our
THE INTERNATIONAL theoretical foundation on which a reha- diagnostic and classification systems.
CLASSIFICATION OF FUNCTIONING, bilitative intervention can be formulat- Many of them also have a history of at-
DISABILITY AND HEALTH ed. Interventions can be classified as re- tempted suicide. All in all they repre-
habilitative in the case that they are sent an utmost difficult-to-treat patient
Long-term consequences of major mainly directed towards a functional population.
mental disorders might be described us- improvement of the affected individual.
ing different dimensions. A useful tool As such, the nature of an intervention is
was provided by the International Classi- defined by the goal which is addressed CONCEPTUAL FRAMEWORK
fication of Impairment, Disability and by the intervention.
Handicaps (ICIDH), first published by The overall philosophy of psychiatric
the World Health Organization in 1980 rehabilitation in mental disorders com-
(3). The ICIDH has been recently re- TARGET POPULATION prises two intervention strategies. The
vised. The revised International Classifi- first strategy is individual-centred and
cation of Functioning, Disability and Although the majority of the chroni- aims at developing the patients skills in

interacting with a stressful environ- his or her own care planning (15). It is ty settings. Providing sheltered housing
ment. The second strategy is ecological essential that the patient can rely on his in the community for the long-term pa-
and directed towards developing envi- or her therapists understanding and tients of the old asylums was one of the
ronmental resources to reduce potential trust (16), as most of the chronically first steps in the process of deinstitu-
stressors. Most disabled persons need a mentally ill and disabled persons lose tionalization. Most long-stay patients
combination of both approaches. close, intimate and stable relationships can successfully leave psychiatric hospi-
The starting point for an adequate in the course of the disease (17). Recent tals and live in community settings (24).
understanding of rehabilitation is that it research has suggested that social sup- Ideally, a residential continuum (RC)
is concerned with the individual person port is associated with recovery from with different housing options should
in the context of his or her specific envi- chronic diseases, greater life satisfaction be provided. RC ranges from round-the-
ronment. Psychiatric rehabilitation is and enhanced ability to cope with life clock staffed sheltered homes to more
regularly carried out under real life con- stressors (18). Corrigan et al (19) have independent and less staffed sheltered
ditions. Thus, rehabilitation practition- found that the most important factor fa- apartments which eventually allow in-
ers have to take into consideration the cilitating recovery is the support of dividuals moving to independent hous-
realistic life circumstances that the af- peers. Therefore, psychiatric rehabilita- ing in the community (25). Critics of RC
fected person is likely to encounter in tion is also an exercise in network build- contended that: a) up to date RC is
his or her day-to-day living (9). ing (20). rarely available in communities, b) RC
A necessary second step is helping Finally, people with mental disorders does not meet the varying and fluctuat-
disabled persons to identify their per- and their caregivers prefer to see them- ing needs of persons with serious men-
sonal goals. This is not a process where selves as consumers of mental health tal illnesses, and c) RC does not account
those persons simply list their needs. services with an active interest in learn- for individuals preferences and choices.
Motivational interviews provide a more ing about mental disorders and in se- Supported housing, i.e. independent
sophisticated approach to identify the lecting the respective treatment ap- housing coupled with the provision of
individuals personal costs and benefits proaches. Consumerism allows the tak- support services (26), emerged in the
associated with the needs listed (10). ing of the affected persons perspective 1980s as an alternative to RC. Support-
This makes it also necessary to assess and seriously considering courses of ac- ed housing offers flexible and individu-
the individuals readiness for change tion relevant for them (21). In this con- alized services depending on the indi-
(11,12). text, physicians should also acknowl- viduals demands. In the meantime, re-
Subsequently the rehabilitative plan- edge that disagreement about the illness habilitation research could demonstrate
ning process focuses on the patients between themselves and the patient is that supported housing is a realistic goal
strengths (9). Irrespective of the degree not always the result of the illness for the majority of people with psychi-
of psychopathology of a given patient, process (22). atric disabilities (27). Once in supported
the practitioner must work with the housing, the majority stay in housing
well part of the ego as there is always and are less likely to become hospital-
an intact portion of the ego to which CURRENT APPROACHES ized. Other outcomes do not yield con-
treatment and rehabilitation efforts can sistent results (27).
be directed (13). This leads to a closely As a general rule, people with psychi-
related concept: the aim of restoring atric disabilities tend to have the same
hope to people who suffered major set- life aspirations as people without dis- Work
backs in self-esteem because of their ill- abilities in their society or culture (23).
ness. As Bachrach (9) states, it is the They want to be respected as au- The beneficial effects of work for
kind of hope that comes with learning to tonomous individuals and lead a life as mental health have been known for
accept the fact of ones illness and ones normal as possible. As such they mostly centuries (28). Therefore, vocational re-
limitations and proceeding from there. desire: a) their own housing, b) an ade- habilitation has been a core element of
Psychiatric rehabilitation cannot be quate education and a meaningful work psychiatric rehabilitation since its be-
imposed. Quite the contrary, psychiatric career, c) satisfying social and intimate ginning. Vocational rehabilitation is
rehabilitation concentrates on the indi- relationships, and d) participation in based on the assumption that work
viduals rights as a respected partner community life with full rights. does not only improve activity, social
and endorses his or her involvement contacts etc., but may also promote
and self-determination concerning all gains in related areas such as self-es-
aspects of the treatment and rehabilita- Housing teem and quality of life, as work and
tion process. These rehabilitation values employment are a step away from de-
are also incorporated in the concept of The objective of psychiatric reforms pendency and a step to integration into
recovery (14). Within the concept of re- since the mid 1950s has been to resettle society. Enhanced self-esteem in turn
covery, the therapeutic alliance plays a chronically mentally ill persons from improves adherence to rehabilitation of
crucial role in engaging the patient in large custodial institutions to communi- individuals with impaired insight (29).

152 World Psychiatry 5:3 - October 2006

Vocational rehabilitation originated crease in the ability to find and keep The results of several controlled stud-
in psychiatric institutions, where the employment (33,34). Links were also ies suggest that disabled individuals can
lack of activity and stimulation led to found between job tenure and non-vo- be taught a wide range of social skills.
apathy and withdrawal of inpatients. cational outcomes, such as improved Social and community functioning im-
Long before the introduction of medica- self-esteem, social integration, relation- prove when the trained skills are rele-
tion, occupational and work therapy ships and control of substance abuse vant for the patients daily life and the
contributed to sustainable improve- (32,35,36). It was also demonstrated environment perceives and reinforces
ments in long-stay inpatients. Today oc- that those who had found long-term the changed behaviour. Unlike medica-
cupational and work therapy are not employment through SE had improved tion effects, benefits from skills training
any longer hospital-based, but represent cognition and quality of life, and better occur slowly. Furthermore, long-term
the starting point for a wide variety of symptom control (32,36). training has to be provided for positive
rehabilitative techniques teaching voca- Although findings regarding SE are effects (31,40-42). Overall, social skills
tional skills (5). encouraging, some critical issues re- training has been shown to be effective
Vocational rehabilitation programs main to be answered. Many individuals in the acquisition and maintenance of
in the community provide a series of in SE obtain unskilled part-time jobs. skills and their transfer to community
graded steps to promote job entry or re- Since most studies only evaluated short life (39,43,44).
entry. For less disabled persons, brief (12-18 months) follow-up periods, the
and focused techniques are used to long-term impact remains unclear. Cur-
teach how they can find a job, fill out rently we do not know which individu- Keeping relationships
applications and conduct employment als benefit from SE and which do not
interviews (30). In transitional employ- (37). After all, we have to realize that As a consequence of deinstitutional-
ment, a temporary work environment is the integration into the labour market ization, the burden of care has increas-
provided to teach vocational skills, does by no means only depend on the ingly fallen on the relatives of the men-
which should enable the affected per- ability of the persons affected to fulfil a tally ill. Informal caregiving significantly
son to move on to competitive employ- work role and on the provision of so- contributes to health care and rehabili-
ment. But all too often the gap between phisticated vocational training and sup- tation (45). Fifty to ninety per cent of
transitional and competitive employ- port techniques, but also on the willing- disabled persons live with their relatives
ment is so wide that the mentally dis- ness of society to integrate its most dis- following acute psychiatric treatment
abled individuals remain in a temporary abled members. (46). This is a task many families do not
work environment. Sheltered work- choose voluntarily. Caregiving imposes
shops providing pre-vocational training a significant burden on families. Those
also quite often prove a dead end for the Building relationships providing informal care face consider-
disabled persons. able adverse health effects, including
One consequence of the difficulties In recent years, social skills training higher levels of stress and depression,
in integrating mentally disabled individ- in psychiatric rehabilitation has be- and lower levels of subjective well be-
uals into the common labour market come very popular and has been wide- ing, physical health and self-efficacy
has been the steady growth of coopera- ly promulgated. The most prominent (47). Additionally, not all families are
tives, which operate commercially with proponent of skills training is Robert equally capable of giving full support for
disabled and non-disabled staff working Liberman, who has designed systemat- their disabled member and willing to re-
together on equal terms and sharing ic and structured skills training since place insufficient health care systems.
management. The mental health profes- the mid 1970s (38). Liberman and his Caregivers regularly experience higher
sionals work in the background, provid- colleagues packaged the skills training levels of burden when they have poor
ing support and expertise (2). in the form of modules with different coping resources and reduced social
Today, the most promising vocation- topics. The modules focus on medica- support (48). But families also represent
al rehabilitation model is supported tion management, symptom manage- support systems, which provide natural
employment (SE). The work of Robert ment, substance abuse management, settings for context-dependent learning
Drake and Deborah Becker decisively basic conversational skills, interper- important for recovery of functioning
influenced the conceptualization of SE. sonal problem solving, friendship and (49). Therefore, there has been a grow-
In their individual placement model, intimacy, recreation and leisure, work- ing interest in helping affected families
disabled persons are placed in compet- place fundamentals, community (re-) since the beginning of care reforms (50).
itive employment according to their entry and family involvement. Each One area of interest deals with the ex-
choices as soon as possible and receive module is composed of skills areas. The pectations of relatives concerning the
all support needed to maintain their skills areas are taught in exercises with provision of care. Relatives quite often
position (31,32). The support provided demonstration videos, role-play and feel ignored, not taken seriously and also
is continued indefinitely. Participation problem solving exercises and in vivo feel insufficiently informed by health pro-
in SE programs is followed by an in- and homework assignments (39). fessionals. They also may feel that their

contribution to care is not appreciated or people with mental illness exhibit better focuses on all aspects of the physical and
that they will be blamed for any patient outcomes regarding psychopathology social environment. The core elements
problems. It is no surprise that there is a and quality of life (68). The importance of CM are the assessment of patient
lot of frustration and resentment among of social integration is underlined even needs, the development of comprehen-
relatives considering the physical, finan- more when considering the subjective sive service plans for the patients and
cial and emotional family burden. availability of support: perceived social the arrangement of service delivery (77).
Family intervention programs have support predicts outcome in terms of re- Over the past two decades, a variety
produced promising results. Family in- covery from acute episodes of mental ill- of different models of CM have been de-
terventions are effective in lowering re- ness (69), community integration (70), veloped which exceed the original idea
lapse rate and also in improving out- and quality of life (35,71,72). that CM mainly intends to link the pa-
come, e.g. psychosocial functioning On the basis of comprehensive re- tient to needed services and to coordi-
(51). Possibly, family interventions can search in this area during the last de- nate those services. Today, most clinical
reduce family burden. Furthermore, the cade, several strategies have been devel- case managers also provide direct ser-
treatment gains are fairly stable (52). oped to fight the stigma and discrimina- vices in the patients natural environ-
But we also have to appreciate that it is tion suffered by those who have mental ment. This model is called intensive
not clear what the effective components illnesses (73). Different research centres case management (ICM). ICM is diffi-
of the different models are (53). Addi- developed interventions directed to spe- cult to distinguish from assertive com-
tionally, family interventions differ in cific target groups relevant for destigma- munity treatment (ACT).
frequency and length of treatment. tization, e.g. students (74) or police offi- Stein and Test have developed the ba-
There are also no criteria for the mini- cers (75). Persons in contact with men- sic components of ACT in the 1970s (78).
mum amount of treatment necessary. tally ill individuals quite often have a The original program was designed as a
Finally, we have to be aware that most more positive attitude. Contact with the community-based alternative to hospital
family interventions were developed in mentally ill persons also reduces social treatment for persons with severe mental
the context of Western societies during distance (62), which is a strong argu- illnesses. A comprehensive range of
deinstitutionalization. Family caregiving ment in favour of community psychiatry. treatment, rehabilitation and support
might be quite different in a different cul- Other initiatives have targeted stigma by services in the community is provided
tural context. This refers to other cul- means of more comprehensive pro- through a multidisciplinary team. ACT is
tures in total as well as to minority grams. The WPA launched one of the in- characterized by an assertive outreach
groups in Western societies (45,48,54). ternationally best-known programs in approach, i.e. interventions are mainly
1996 (76). All these initiatives make provided in the natural environment of
clear that efforts in re-integrating per- the disabled individuals (79).
Participation in community life sons with serious mental illness into Research on CM and ACT yielded
with full rights community life must be accompanied by mixed results (80). While the tradi-
measures on the societal level. tional office-based CM approach obvi-
As practitioners, we are often con- ously is less successful, the ACT model
fronted with the deleterious effects of was found to be more beneficial when
stigma and discrimination in the lives of DEVELOPING ENVIRONMENTAL compared with standard care (81). ACT
people with serious mental illnesses. RESOURCES can reduce time in hospital (37), but has
Numerous studies have examined stig- moderate or only little effects on im-
matizing attitudes toward people with Effective psychiatric rehabilitation proving symptomatology and social
mental illness (55-62). In recent years, requires individualized and specialized functioning (82). The differing features
the scientific interest in the perspective treatment, which has to be embedded in of the respective services might explain
of the labeled individual has increased a comprehensive and coordinated sys- the international variation. Six regularly
too. There is extensive empirical evi- tem of rehabilitative services. But, even occurring features of successful services
dence of the negative consequences of when a variety of services are available, were identified: smaller case loads, reg-
labeling and perceived stigmatization. they are poorly linked in many cases, ularly visiting at home, a high percent-
These include demoralization, low qual- and costly duplication may occur. age of contacts at home, responsibility
ity of life, unemployment and reduced While developing community sup- for health and social care, multidiscipli-
social networks (63-67). Once assigned port systems, it became obvious that nary teams and a psychiatrist integrated
the label mental illness and having be- there was a need to coordinate and inte- in the team (83).
come aware of the related negative grate the services provided, as each in-
stereotypes, the affected individuals ex- volved professional concentrates on dif-
pect to be rejected, devaluated or dis- ferent aspects of the same patient. THE ROLE OF THE PSYCHIATRIST
criminated. This vicious cycle decreases Therefore, as a key coordinating and in- IN REHABILITATION
the chance of recovery and normal life. tegrating mechanism, the concept of
On the other hand, well-integrated case management (CM) originated. CM The final ingredient of a successful

154 World Psychiatry 5:3 - October 2006

ACT approach, namely a psychiatrist to symptom control, and not trained in current treatment and rehabilitation
integrated in a community team, in- integrating pharmacological and psy- practice has to be substantially im-
evitably leads to the question: what is or chosocial interventions (88). Another proved in the light of the rehabilitation
can be the role of a psychiatrist in reha- side effect of hospital-based training is research available.
bilitation? According to Cancro (84), that young psychiatrists are confronted
A properly trained psychiatrist will be with the negative developments of diffi-
able to prescribe psychosocial interven- cult-to-treat patients who are frequently References
tions, such as social skills training, as re-hospitalized. This is possibly one of
1. Anthony W, Cohen M, Farkas M et al. Psy-
well as prescribe medication. This does the reasons why we found that psychia- chiatric rehabilitation, 2nd ed. Boston:
not mean that the individual psychia- trists in institutional settings do not Center for Psychiatric Rehabilitation,
trist should be able to do everything hold fewer stereotypes of mentally ill Boston University, 2002.
from social skills training to vocational people than the general population, nor 2. Grove B. Reform of mental health care in
rehabilitation to psychoeducation to display a greater willingness to closely Europe. Progress and change in the last
decade. Br J Psychiatry 1994;165:431-3.
family support. It does mean, however, interact with mentally ill people (89). 3. World Health Organization. International
that the psychiatrist must know what is Therefore, it would be beneficial if the Classification of Impairments, Disabilities
needed and where it can be found and community training of young psychia- and Handicaps. Geneva: World Health Or-
must be able to play a role in directing a trists could take priority over hospital- ganization, 1980.
team of professionals who can serve based training. More training opportu- 4. World Health Organization. International
Classification of Functioning, Disability
these patients. Not only will the patients nities to experience the patients in the and Health (ICF). Geneva: World Health
benefit from such an approach but so real world would allow psychiatrists Organization, 2001.
will our discipline. in institutional settings to develop a 5. Royal College of Psychiatrists. Psychiatric
Psychiatric rehabilitation is by its more positive perspective and better un- rehabilitation. Revised. London: Gaskell,
very nature multidisciplinary, because derstanding of persons with severe and 1996.
6. Goldman HH, Gattozzi AA, Taube CA.
of the many different competencies re- persistent mental disorders. Defining and counting the chronically men-
quired (85). It goes without saying that tally ill. Hosp Commun Psychiatry 1981;32:
monitoring medication is a key task of 21-7.
the psychiatrist. But pharmacotherapy OUTLOOK 7. Cuffel B. Comorbid substances use disor-
in psychiatric rehabilitation needs some der: prevalence, patterns of use, and course.
In: Drake R, Mueser K (eds). Dual diagno-
special consideration. Symptom con- Up to date, major developments in sis of major mental illness and substance
trol does not necessarily have the high- psychiatric treatment and care have disorder: recent research and clinical impli-
est priority, as some side effects of phar- evolved from psychiatric rehabilitation. cations. San Francisco: Jossey-Bass, 1996:
macological treatment can weaken a This is the most visible part of psychi- 93-105.
persons ability to perform his or her so- atric care and as such represents the 8. Schwartz S, Goldfinger S, Ratener M et al.
The young adult patient and the care sys-
cial roles, and impair vocational reha- link to society. The attitude of the pub- tem: fragmentation prototypes. San Fran-
bilitation. As such, it is no surprise that lic towards psychiatry is mostly influ- cisco: Jossey-Bass, 1983.
non-compliance with medication tak- enced by what rehabilitation accom- 9. Bachrach LL. Psychosocial rehabilitation
ing is one of the most serious problems plishes or not. In fact, the US Presi- and psychiatry in the treatment of schizo-
in the long-term treatment of persons dents Freedom Commission on Mental phrenia - what are the boundaries? Acta
Psychiatr Scand 2000;102(Suppl. 407):6-10.
with serious mental illness (86). Many Health (90) declared that helping af- 10. Corrigan PW, McCracken SG, Holmes EP.
patients living in the community want fected persons to achieve functional re- Motivational interviews as goal assessment
to take responsibility for their medica- covery is the main purpose of the men- for persons with psychiatric disability.
tion themselves. Training in self-man- tal health care system. Commun Ment Health J 2001;37:113-22.
agement of medication (87) empha- The refinement of psychiatric reha- 11. Rogers ES, Martin R, Anthony W et al. As-
sessing readiness for change among per-
sizes patients autonomy and increases bilitation has achieved a point where it sons with severe mental illness. Commun
acceptance of and responsibility for should be made readily available for Ment Health J 2001;37:97-112.
treatment. This also includes the change every disabled person. But we have to 12. Liberman RP, Wallace CJ, Hassell J. Rehab
of medication without consultation be aware that there is a long way be- rounds: predicting readiness and respon-
within certain limits. tween research and practice. Lehman siveness to skills training: the Micro-Mod-
ule Learning Test. Psychiatr Serv 2004;55:
As a matter of course, most psychia- and Steinwachs (91), for example, as- 764-6.
trists do not acquire all relevant skills sessed the patterns of usual care for 13. Lamb HR. Treating the long-term mentally
needed in psychiatric rehabilitation schizophrenic patients and examined ill: beyond deinstitutionalization. San Fran-
during their training, which is predomi- the conformance rate with the treat- cisco: Jossey-Bass, 1982.
nantly hospital-based. Young psychia- ment recommendations based on exist- 14. Farkas M, Gagne C, Anthony W et al. Im-
plementing recovery oriented evidence
trists today are primarily trained in diag- ing scientific evidence. The confor- based programs: identifying the critical di-
nostic procedures and prescription of mance rate was modest, generally be- mensions. Commun Ment Health J 2005;
medications directed almost exclusively low 50%. It seems to be obvious that 41:141-58.

15. Priebe S, McCabe R, Bullenkamp J et al. atric rehabilitation: recent findings. Int Rev schizophrenia: results of the BIOMED I
The impact of routine outcome measure- Psychiatry 1998;19:9-19. study. Soc Psychiatry Psychiatr Epidemiol
ment on treatment processes in community 32. Bond GR. Supported employment: evi- 1998;33:405-12.
mental health care: approach and methods dence for an evidence-based practice. Psy- 49. Schooler NR. Integration of family and drug
of the MECCA study. Epidemiol Psichiatr chiatr Rehabil J 2004;27:345-59. treatment strategies in the treatment of
Soc 2002;11:198-205. 33. Baronet AM, Gerber GJ. Psychiatric reha- schizophrenia: a selective review. Int Clin
16. Tuttman S. Protecting the therapeutic al- bilitation: efficacy of four models. Clin Psy- Psychopharmacol 1995;10(Suppl. 3):73-80.
liance in this time of changing health-care chol Rev 1998;18:189-228. 50. Strachan AM. Family intervention for the
delivery systems. Int J Group Psychother 34. Cook JA, Lehman AF, Drake R et al. Inte- rehabilitation of schizophrenia: toward
1997;47:3-16. gration of psychiatric and vocational serv- protection and coping. Schizophr Bull
17. Barbato A, Monzani E, Schiavi T. Life sat- ices: a multisite randomized, controlled tri- 1986;12:678-98.
isfaction in a sample of outpatients with se- al of supported employment. Am J Psychia- 51. Koukia E, Madianos MG. Is psychosocial
vere mental disorders: a survey in northern try 2005;162:1948-56. rehabilitation of schizophrenic patients
Italy. Qual Life Res 2004;13:969-73. 35. Ruesch P, Graf J, Meyer PC et al. Occupa- preventing family burden? A comparative
18. Rogers ES, Anthony W, Lyass A. The na- tion, social support and quality of life in study. J Psychiatr Ment Health Nurs 2005;
ture and dimensions of social support persons with schizophrenic or affective dis- 12:415-22.
among individuals with severe mental ill- orders. Soc Psychiatry Psychiatr Epidemiol 52. Pilling S, Bebbington P, Kuipers E et al.
nesses. Commun Ment Health J 2004;40: 2004;39:686-94. Psychological treatments in schizophrenia:
437-50. 36. Salyers MP, Becker DR, Drake RE et al. A I. Meta-analysis of family intervention and
19. Corrigan PW, Slopen N, Gracia G et al. ten-year follow-up of a supported employ- cognitive behaviour therapy. Psychol Med
Some recovery processes in mutual-help ment program. Psychiatr Serv 2004;55: 2002;32:763-82.
groups for persons with mental illness; II: 302-8. 53. Barbato A, DAvanzo B. Family interven-
qualitative analysis of participant inter- 37. Mueser KT, Bond GR, Drake RE et al. tions in schizophrenia and related disor-
views. Commun Ment Health J 2005;41: Models of community care for severe men- ders: a critical review of clinical trials. Acta
721-35. tal illness: a review of research on case man- Psychiatr Scand 2000;102:81-97.
20. Cutler DL. Clinical care update. The agement. Schizophr Bull 1998;24:37-74. 54. Guarnaccia PJ. Multicultural experiences
chronically mentally ill. Commun Ment 38. Liberman R. Psychiatric rehabilitation of of family caregiving: a study of African
Health J 1985;21:3-13. chronic mental patients. Washington: American, European American, and His-
21. Kopelowicz A, Liberman RP. Biobehavioral American Psychiatric Press, 1988. panic American families. New Dir Ment
treatment and rehabilitation of schizophre- 39. Liberman RP, Kopelowicz A. Teaching per- Health Serv 1998;77:45-61.
nia. Harv Rev Psychiatry 1995;3:55-64. sons with severe mental disabilities to be 55. Bhugra D. Attitudes towards mental ill-
22. Bebbington PE. The content and context of their own case managers. Psychiatr Serv ness. A review of the literature. Acta Psy-
compliance. Int Clin Psychopharmacol 2002;53:1377-9. chiatr Scand 1989;80:1-12.
1995;9(Suppl. 5):41-50. 40. Penn DL, Mueser KT. Research update on 56. Jorm AF. Mental health literacy. Public
23. Onken SJ, Dumont JM, Ridgway P et al. the psychosocial treatment of schizophre- knowledge and beliefs about mental disor-
Mental health recovery: what helps and nia. Am J Psychiatry 1996;153:607-17. ders. Br J Psychiatry 2000;177:396-401.
what hinders? A national research project 41. Glynn SM, Marder SR, Liberman RP et al. 57. Lauber C, Nordt C, Falcato L et al. Lay rec-
for the development of recovery facilitating Supplementing clinic-based skills training ommendations on how to treat mental dis-
system performance indicators. www.rfmh. with manual-based community support orders. Soc Psychiatry Psychiatr Epidemiol
org/csipmh/projects/rc10.shtm. sessions: effects on social adjustment of pa- 2001;36:553-6.
24. Barbato A, DAvanzo B, Rocca G et al. A tients with schizophrenia. Am J Psychiatry 58. Stuart H, Arboleda-Florez J. Community
study of long-stay patients resettled in the 2002;159:829-37. attitudes toward people with schizophre-
community after closure of a psychiatric 42. Bellack AS. Skills training for people with nia. Can J Psychiatry 2001;46:245-52.
hospital in Italy. Psychiatr Serv 2004;55: severe mental illness. Psychiatr Rehabil J 59. Gaebel W, Baumann A, Witte AM et al.
67-70. 2004;27:375-91. Public attitudes towards people with men-
25. Ridgway P, Zipple AM. The paradigm shift 43. Roder V, Zorn P, Muller D et al. Improving tal illness in six German cities: results of a
in residential services: from linear continu- recreational, residential, and vocational public survey under special consideration
um to supported housing approaches. Psy- outcomes for patients with schizophrenia. of schizophrenia. Eur Arch Psychiatry Clin
chosoc Rehabil J 1990;13:11-32. Psychiatr Serv 2001;52:1439-41. Neurosci 2002;252:278-87.
26. Carling PJ. Housing, community support, 44. Liberman RP, Glynn S, Blair KE et al. In vi- 60. Lauber C, Nordt C, Falcato L et al. Public
and homelessness: emerging policy in men- vo amplified skills training: promoting gen- attitude to compulsory admission of men-
tal health systems. N Engl J Publ Policy eralization of independent living skills for tally ill people. Acta Psychiatr Scand 2002;
1992;8:281-95. clients with schizophrenia. Psychiatry 105:385-9.
27. Rog DJ. The evidence on supported hous- 2002;65:137-55. 61. Angermeyer MC, Matschinger H. Public
ing. Psychiatr Rehabil J 2004;27:334-44. 45. Schulze B, Rssler W. Caregiver burden in beliefs about schizophrenia and depression:
28. Harding CM, Strauss JS, Hafez H et al. mental illness: review of measurement, similarities and differences. Soc Psychiatry
Work and mental illness. I. Toward an inte- findings and interventions in 2004-2005. Psychiatr Epidemiol 2003;38:526-34.
gration of the rehabilitation process. J Nerv Curr Opin Psychiatry 2005;18:684-91. 62. Lauber C, Nordt C, Falcato L et al. Factors
Ment Dis 1987;175:317-26. 46. Lauber C, Eichenberger A, Luginbuhl P et influencing social distance toward people
29. McElroy EM. Sources of distress among al. Determinants of burden in caregivers of with mental illness. Commun Ment Health
families of the hospitalized mentally ill. patients with exacerbating schizophrenia. J 2004;40:265-74.
New Dir Ment Health Serv 1987;34:61-72. Eur Psychiatry 2003;18:285-9. 63. Link BG, Struening EL, Rahav M et al. On
30. Jacobs H, Kardashian S, Kreinbring R et al. 47. Hirst M. Carer distress: a prospective, pop- stigma and its consequences: evidence
A skills-oriented model for facilitating em- ulation-based study. Soc Sci Med 2005;61: from a longitudinal study of men with dual
ployment in psychiatrically disabled per- 697-708. diagnoses of mental illness and substance
sons. Rehabil Counsel Bull 1988;27:96-7. 48. Magliano L, Fadden G, Madianos M et al. abuse. J Health Soc Behav 1997;38:177-90.
31. Wallace CJ. Social skills training in psychi- Burden on the families of patients with 64. Mechanic D, McAlpine D, Rosenfield S et

156 World Psychiatry 5:3 - October 2006

al. Effects of illness attribution and depres- Does the place of treatment influence the The REACT study: randomised evaluation
sion on the quality of life among persons quality of life of schizophrenics? Acta Psy- of assertive community treatment in north
with serious mental illness. Soc Sci Med chiatr Scand 1999;100:142-8. London. Br Med J 2006;332:815-20.
1994;39:155-64. 73. Rusch N, Angermeyer MC, Corrigan PW. 83. Burns T, Catty J, Wright C. De-constructing
65. Rosenfield S. Labeling mental illness: the Mental illness stigma: concepts, conse- home-based care for mental illness: can one
effects of received services and perceived quences, and initiatives to reduce stigma. identify the effective ingredients? Acta Psy-
stigma on life satisfaction. Am Soc Rev Eur Psychiatry 2005;20:529-39. chiatr Scand 2006;113(Suppl. 429):33-5.
1997;62:660-72. 74. Meise U, Sulzenbacher H, Kemmler G et 84. Cancro R. The introduction of neurolep-
66. Graf J, Lauber C, Nordt C et al. Perceived al. Not dangerous, but nevertheless fright- tics: a psychiatric revolution. Psychiatr Serv
stigmatization of mentally ill people and its ening. A program against stigmatization of 2000;51:333-5.
consequences for the quality of life in a schizophrenia in schools. Psychiatr Prax 85. Liberman RP, Hilty DM, Drake RE et al.
Swiss population. J Nerv Ment Dis 2004; 2000;27:340-6. Requirements for multidisciplinary team-
192:542-7. 75. Pinfold V, Huxley P, Thornicroft G et al. Re- work in psychiatric rehabilitation. Psychia-
67. Mueller B, Nordt C, Lauber C et al. Social ducing psychiatric stigma and discrimina- tr Serv 2001;52:1331-42.
support modifies perceived stigmatization tion - evaluating an educational intervention 86. Dencker SJ, Liberman RP. From compli-
in the first years of mental illness: a longi- with the police force in England. Soc Psy- ance to collaboration in the treatment of
tudinal approach. Soc Sci Med 2006;62: chiatry Psychiatr Epidemiol 2003;38:337-44. schizophrenia. Int Clin Psychopharmacol
39-49. 76. Stuart H, Arboleda-Florez J, Sartorius N 1995;9(Suppl. 5):75-8.
68. Becker T, Leese M, Clarkson P et al. Links (eds). Stigma in mental disorders: interna- 87. Eckman TA, Liberman RP, Phipps CC et al.
between social network and quality of life: tional perspectives. World Psychiatry Teaching medication management skills to
an epidemiologically representative study 2005;4(Suppl. 1):1-62. schizophrenic patients. J Clin Psychophar-
of psychotic patients in south London. Soc 77. Rssler W, Loffler W, Fatkenheuer B et al. macol 1990;10:33-8.
Psychiatry Psychiatr Epidemiol 1998;33: Does case management reduce the rehospi- 88. Liberman RP, Glick ID. Drug and psy-
229-304. talization rate? Acta Psychiatr Scand 1992; chosocial curricula for psychiatry residents
69. George LK, Blazer DG, Hughes DC et al. 86:445-9. for treatment of schizophrenia: part I. Psy-
Social support and the outcome of major 78. Stein LI, Test MA. Alternative to mental chiatr Serv 2004;55:1217-9.
depression. Br J Psychiatry 1989;154:478- hospital treatment. I. Conceptual model, 89. Nordt C, Rssler W, Lauber C. Attitudes of
85. treatment program, and clinical evaluation. mental health professionals toward people
70. Hall GB, Nelson G. Social networks, social Arch Gen Psychiatry 1980;37:392-7. with schizophrenia and major depression.
support, personal empowerment, and the 79. Scott JE, Dixon LB. Assertive community Schizophr Bull (in press).
adaptation of psychiatric consumers/sur- treatment and case management for schiz- 90. Health PsNFCoM. Achieving the promise:
vivors: path analytic models. Soc Sci Med ophrenia. Schizophr Bull 1995;21:657-68. transforming mental health care in America.
1996;43:1743-54. 80. Burns T, Fioritti A, Holloway F et al. Case
71. Yanos PT, Rosenfield S, Horwitz AV. Nega- management and assertive community ports/Finalreport/toc_exec.html.
tive and supportive social interactions and treatment in Europe. Psychiatr Serv 2001; 91. Lehman AF, Steinwachs DM. Patterns of
quality of life among persons diagnosed 52:631-6. usual care for schizophrenia: initial results
with severe mental illness. Commun Ment 81. Marshall M. Case management: a dubious from the Schizophrenia Patient Outcomes
Health J 2001;37:405-19. practice. Br Med J 1996;312:523-4. Research Team (PORT) Client Survey.
72. Rssler W, Salize HJ, Cucchiaro G et al. 82. Killaspy H, Bebbington P, Blizard R et al. Schizophr Bull 1998;24:11-20.