5 Organisation and delivery of psychiatric services5.5 Rehabilitation services
5.5 Psychiatric rehabilitation
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Written by Resident Doctor Committee · Published
Purpose and caseload
Rehabilitation helps people with persistent psychiatric disability regain autonomy, roles and community life, even when symptoms remain.
Psychotic disorders, above all schizophrenia and schizoaffective disorder, make up most of the caseload of UK inpatient rehabilitation units. These units serve complex, treatment-resistant psychosis rather than mirroring population prevalence.
Clinical and personal recovery
Aspect | Clinical recovery | Personal recovery |
|---|---|---|
Defined by | Services | The person |
Markers | Symptom remission, discharge, independent living or work | A satisfying, hopeful life with personal meaning |
Persisting symptoms | Remission is the aim | A good life can coexist with symptoms |
The recovery model aims at personal recovery and is strengths-based. Care starts from the person's abilities and resources rather than their impairments, so a strengths-based assessment expresses it.
The 2004 SAMHSA National Consensus Statement on Mental Health Recovery lists components of recovery-oriented services. These include self-direction, peer support, strengths-based practice, non-linearity and personal rather than clinical recovery.
CHIME summarises personal recovery: connectedness, hope, identity, meaning and empowerment.
Assessment and treatment
Assess negative and cognitive symptoms, daily living skills, physical health, substance use, vulnerability to exploitation, and the person's strengths and goals.
Optimise medication and check for an adequate clozapine trial in treatment-resistant psychosis.
Offer cognitive behavioural therapy for psychosis, family intervention, cognitive remediation and graded skills practice.
Vocational rehabilitation
Supported employment, in its manualised form Individual Placement and Support (IPS), is the best-evidenced vocational intervention in chronic psychosis. It outperforms train-then-place, sheltered and skills-based approaches, roughly doubling competitive employment rates.
Model | How it works |
|---|---|
IPS: place then train | Zero exclusion, rapid search for open-market work, respect for the person's preferences, time-unlimited support, employment specialist inside the clinical team |
Prevocational training: train then place | Months of skills practice in a protected setting, with job search deferred until staff judge the person ready |
Transitional employment | The programme, not the worker, owns the posts, which are filled in rotation part-time for about six months, with staff covering absences |
Social firm | Trades on the open market, over a quarter of staff disabled or disadvantaged, market wages on equal terms, grew from Italian worker cooperatives |
Housing
Model | Route to a tenancy |
|---|---|
Staircase | The person moves up levels of support after showing readiness |
Housing first | Tenancy first, then support; stronger evidence for housing stability in homelessness with complex mental health or substance use needs |
Institutionalism and positive risk-taking
Wing and Brown linked long-stay hospital environments with apathy, withdrawal, reduced initiative and poverty of speech. This is disability beyond what the illness causes.
Positive risk-taking accepts a proportionate, identified risk in pursuit of a goal the person values. Staff document the reasoning and agree contingency plans.
Pathway and review
The pathway runs from inpatient rehabilitation lasting months to a few years, through community rehabilitation, to an independent tenancy with community mental health follow-up.
NICE recommends reviewing the care plan at least monthly in inpatient rehabilitation and six-monthly in community rehabilitation.