Recovery and rehabilitation

The modern idea of rehabilitation is helping patients in the community, with any kind of mental health problem, gradually return to normal functioning. The currently fashionable recovery model emphasizes positive aspects of individual patients, building strengths, so that they recover their full potential even though they need continuing support from mental health services.

This stands in complete contrast to the old idea of rehabilitation, which was restricted to severely affected psychotic patients. That old idea conjures up pictures of the long-stay 'back wards' of the old psychiatric hospitals, where deteriorated patients with schizophrenia would be rewarded with cigarettes, in return for performing simple tasks such as self-care. Such programmes of 'token economy' would, of course, now be regarded as unethical.

Rehabilitation aims to reduce disablement, or better still to prevent it, through early intervention, and to improve social functioning and quality of life. This might involve a worthwhile occupation and a stable social network, preferably involving the family, in addition to psychiatric symptom control. Individual programmes take account of each patient's impairments, positive attributes, and likely future environment. Progress toward agreed goals is often achieved gradually. Rehabilitation is part of everyday care, not something to be seen as separate.

Many patients have always done well, and there is the potential to improve outcomes and functioning for most patients through appropriate rehabilitation - in particular, vocational rehabilitation (http://www.vocationalrehabilitationas-sociation.org.uk/); that is, getting patients back to work so that they can benefit from the positive effects of having routine, social contact, and from improved self-esteem and self-confidence (and possibly improved finances, although the extremely complex benefit system may provide perverse incentives against paid work).

Old-fashioned 'sheltered employment' is now uncommon, but there are various schemes in different areas that seek to encourage people with health problems to get back to work; the Disability Employment Adviser at the job centre can help. Doing college courses or voluntary work can be very helpful first steps in rehabilitation.

In the case of patients who have an existing job, graduated return to work programmes can be very helpful in returning patients to work. In the case of neurotic symptoms such as anxiety and depression, we should be moving toward a presumption that they do not prevent work once the acute stage is passed. Patients do lose confidence, but prolonged absence can result in a vicious cycle and become a self-fulfilling prophecy; the well-known therapeutic benefits of work and the converse risks to health of not working are increasingly recognized.

Working patients who become unwell have legal rights that may protect their employment under the Disability Discrimination Act.

Severe, prolonged psychiatric illness, notably chronic schizophrenia, may lead to loss of daily living skills and/or socially undesirable behaviour. The result may be breakdown of family relationships, homelessness, poverty, and unemployment. However, it is clear that some patients in the past have developed these associated problems at least partly because they coincided with expectations of society and of services.

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