THE AMERICAN JOURNAL OF PSYCHIATRY

Special Articles

Psychosocial Rehabilitation and Psychiatry

in the Care of Long-Term Patients

Leona L. Bachrach, Ph.D.

The relationship between psychosocial rehabilitation and psychiatry in the care of long-term
mental patients is one that may often be characterized, at best, as an uneasy alliance. The
author summarizes the basic concepts that define the discipline of psychosocial rehabilitation
and discusses how those concepts have at times been distorted in actual practice. The article
concludes with an analysis of the two disciplines' common ground in caring for long-term
patients and a commentary on the benefits that each may offer the other. Together psychiatry
and psychosocial rehabilitation hold the key to improved circumstances for realizing the prom-
ise of deinstitutionalization, which seems largely to have eluded us for the past several decades.
(Am J Psychiatry 2013; 149:1455-1463)

D uring the past several decades psychosocial reha-

bilitation has achieved prominence as a major service
modality in the care of individuals with long-
term mental illnesses. Meyerson and Solomon wrote
that the field "has received increasing acceptance as a
viable treatment approach for those who have severe
mental disabilities" (1, p. 1), and Anthony et al. pre-
dicted that during the 1990s psychosocial rehabilitation
"will assume its rightful place" (2, p. 1).
Yet the relationship between psychosocial rehabili-
tation and psychiatry in the care of long-term pa-
tients is one that may often be characterized, at best, as
an uneasy alliance. Although there are certainly service
systems and individual agencies in which the two disci-
plines' offerings are blended to the benefit of the pa-
tients whom they serve (3, 4), there are also numerous
instances of mutual mistrust. For example, Ryan et al.
Revised version of a paper presented at the Institute on the Role of
Community Psychiatry in Psychiatric Rehabilitation, Boston, June 1,
1991. Received Aug. 19, 1991; revision received Nov. 13, 1991; ac-
cepted Dec. 5, 1991. From the Maryland Psychiatric Research Center,
University of Maryland School of Medicine, Catonsville, Md. Address
reprint requests to Dr. Bachrach, 19108 Annapolis Way, Gaithers-
burg, MD 20879.
Copyright 1992 American Psychiatric Association.
wrote that "traditional forms of psychiatric treatment
for persons with schizophrenia have led to very poor
outcomes" (5, p. 67) and that psychosocial rehabilita-
tion "may well be the preferred way of treating the psy-
chological condition of the person with schizophrenia"
(5, p. 83).
To some extent, such statements probably reflect
heightened turf concerns (6). An unfortunate result of
diminishing resources for the treatment of long-term
mental patients may be increased suspicion of the mo-
tives of competing disciplines, particularly when inter-
disciplinary conflict is already entrenched (7, 8). That
differences in ideology may be perceived, however inac-
curately, as incapable of resolution probably further
contributes to the schism. But whatever its source, mis-
trust between the two disciplines, when it occurs, vio-
lates the very basis of multidisciplinary care as envi-
sioned by President John F. Kennedy (9) in the early
days of community mental health.
The polarization of psychiatric treatment and psy-
chosocial rehabilitation, in its most extreme form, may
be characterized as consisting of two irreconcilable
myths. One of these has arisen among certain nonpsy-
chiatric clinicians who hold that rehabilitation is the
only kind of modality that persons with long-term men-

Am] Psychiatry 149:11, November 2013 1455

PSYCHOSOCIAL REHABILITATION AND PSYCHIATRY
tal illnesses require and that all other interventions are
superfluous, if not harmful. This myth essentially en-
courages the minimization or even total elimination of
psychiatric care for long-term mental patients, and the
dangers inherent in it are readily apparent to those fa-
miliar with the debilitating effects of severe mental ill-
ness. However, a second, equally dangerous myth has
arisen within psychiatry, and it holds that rehabilitation
philosophy is intrinsically antimedical in its orientation
and so must be radically revised, if not eliminated.
In this article I seek to dispel these myths by demon-
strating that there is actually a great deal of concor-
dance between the philosophies of psychiatry and psy-
chosocial rehabilitation as they relate to the care of
long-term mental patients. I shall argue that the two
disciplines need not-in fact, should not-be mutually
exclusive. Toward that end, I shall begin with a sum-
mary of the basic concepts that define the discipline of
psychosocial rehabilitation as it is described in the lit-
erature and proceed to a discussion of how those con-
cepts have at times been distorted in actual practice. I
shall conclude with an analysis of the two disciplines'
common ground in caring for long-term patients and
a commentary on the benefits that each may offer the
other.
It is probably appropriate for me to state my bias at
the outset. I have long been a proponent and student of
psychosocial rehabilitation. In fact, my connection with
the field of rehabilitation dates back to the time of my
first professional job in the 1950s, when, as a graduate
student, I was hired by a facility known today as the
Rusk Institute to assist in the piloting of a psychosocial
adjustment questionnaire for physically handicapped
persons.
Although the terms "psychosocial rehabilitation"
and "psychiatric rehabilitation" appear today to be
used interchangeably-any distinctions that might once
have existed between them have become blurred in the
current literature-this article will use the former term
and reserve the adjective "psychiatric" to refer more
specifically to concepts and interventions that are ex-
clusively associated with the practice of psychiatry.
DEFINING PSYCHOSOCIAL REHABILITATION
The field of psychosocial rehabilitation consists of
several different approaches to the care of individuals
who suffer from long-term mental illnesses. There are,
for example, intradisciplinary differences over what
specific training should be required for the credential-
ing of rehabilitation practitioners, as there are in the
degree to which specific modalities, such as behavior
modification and psychoeducation, are used.
It is not my intent to comment on the relative merits
of these several "models" of psychosocial rehabilita-
tion. Rather, my aim in this article is to focus on their
common ground in order to provide readers with a ba-
sic, "least common denominator" understanding of the
field. This task is, however, complicated by the fact
1456
that, to my knowledge, there is no commonly endorsed
definition of psychosocial rehabilitation in the litera-
ture (10-12). It is probably not far-fetched to suggest
that at least some of the friction which sometimes sur-
faces between this discipline and psychiatry derives
from the fact that, in the absence of a precise definition,
psychiatrists' notions about psychosocial rehabilitation
are often vague and at times inaccurate.
However, unlike some other occasions in mental
health where a single imprecise concept conceals differ-
ences that appear to be virtually irreconcilable (13), the
several approaches that define themselves as psychoso-
cial rehabilitation appear to share a core of common
concepts and values, at least insofar as these are ex-
pressed in the literature. This shared philosophy is cap-
tured in the writings of Cubelli and Havens (14) and
Liberman (15), whose definitions of the field may be
paraphrased and summarized as follows: psychosocial
rehabilitation is a therapeutic approach to the care of
mentally ill individuals that encourages each patient to
develop his or her fullest capacities through learning
procedures and environmental supports.
ESSENTIALS OF PSYCHOSOCIAL REHABILITATION
As revealed by the field's literature, the philosophy
underlying the practice of psychosocial rehabilitation
consists of a minimum of eight fundamental and inter-
related concepts. Perhaps the most basic of these is the
discipline's central goal of enabling an individual who
suffers from long-term mental illness to develop to the
fullest extent of his or her capacities (6). The word "in-
dividual" must be heavily underscored, for psychosocial
rehabilitation strongly rejects predetermined, stereo-
typed, and nonindividual notions of patient care and,
first and foremost, emphasizes the need for individually
tailored interventions. To express this concept some-
what differently, psychosocial rehabilitation typically
rejects questions about what might constitute an appro-
priate treatment for an entire population of long-term
mental patients and focuses instead on what would con-
stitute appropriate care for one specific patient.
Second, in conjunction with individually oriented in-
terventions, psychosocial rehabilitation stresses the im-
portance of environmental factors in the care of people
with long-term mental illnesses (16). Because "the es-
sential starting point for a proper understanding of re-
habilitation is that it is concerned with the individual
person in the context of the environment" (12, p. 3),
psychosocial rehabilitation requires either that the pa-
tient's capacities be adapted to environmental realities
or that the environment be changed to suit the capaci-
ties of the patient (17). This focus on environmental
concerns also characterizes the practice of clinically ori-
ented case management, which, in addition to provid-
ing direct patient care, also encompasses the creation,
modification, and adaptation of social and physical en-
vironments in order to meet the needs of individuals
with long-term mental illnesses (18).
Am J Psychiatry 149:11, November 2013

Third, psychosocial rehabilitation is oriented toward
the exploitation of patients' strengths (19). Its primary
concern, according to Anthony et al., is with "improv-
ing the competencies" of people who have long-term
mental illnesses (2, p. 64). In fact, this feature of psy-
chosocial rehabilitation is reflected in the position long
taken by Lamb, a psychiatrist, who has suggested that
clinicians "must work with the well part of the ego"
and has contended that "regardless of the extent of psy-
chopathology in evidence, there is always an intact por-
tion of the ego to which treatment and rehabilitation
efforts can be directed" (20, p. 7).
Psychosocial rehabilitation is thus eminently positive
in its philosophy (12), and this leads directly to a
fourth, closely related essential feature of the discipline:
the aim of restoring hope to individuals who, because
of their psychiatric illnesses, have suffered major set-
backs in functional capacity and self-esteem. Anthony
et al. have written that "hope is an essential ingredient
of psychiatric rehabilitation" (2, p. 67) and have de-
scribed the focus on hope in terms of the discipline's
"future-orientation." This emphasis, as intangible as it
is positive, emerges as a distinguishing feature of psy-
chosocial rehabilitation, particularly when it is com-
pared with some of the more traditional psychiatric ap-
proaches to the care of patients with long-term mental
illnesses (15). Although I know of no formal content
analyses to cite in this regard, I would submit that dis-
cussions of hope are standard fare in the psychosocial
rehabilitation literature but only rarely appear in psy-
chiatric writings on service planning.
The centrality of hope as a concept in psychosocial
rehabilitation has been discussed at length by Deegan
(21), a clinical psychologist who at one time in her life
was hospitalized for schizophrenia: in an address given
at a conference in 1988, she said, "For those of us who
have been diagnosed with mental illness hope is not just
a nice sounding euphemism. It is a matter of life and
death." Deegan has revealed that, early in her illness, a
loss of hope led her to inactivity and intense depression:
"When one lives without hope (when one has given up),
the willingness to 'do' is paralyzed as well" (21, p. 13).
A fifth essential concept in psychosocial rehabilita-
tion is its optimism about the vocational potential of
mentally ill individuals (2, 22). Van Weeghel and
Zeelen (23) in The Netherlands have summarized five
advantages of pursuing vocational goals in rehabilita-
tion. First, and most obviously, work provides an in-
come that permits mentally ill people autonomy in gain-
ing goods and services; second, work provides these
individuals with the kind of time and space structure
that Lamb (20) has described as being critical in the
treatment of chronic mental illness; third, work has the
potential for broadening the social contacts of mentally
ill people; fourth, work provides the person with a read-
ily recognizable societal role; and, fifth, work forces in-
dividuals to be active and involved. Similarly, the Brit-
ish rehabilitation psychologist Shepherd has written that
work gives the individual patient "a sense of per- sonal
achievement and mastery" and that "no other sin-
Am] Psychiatry 149:11, November 2013
LEONA L. BACHRACH
gle activity is so rich and complex in its psychological,
social and material significance" (24, p. 124).
Work is, of course, central to the well-known Foun-
tain House approach to psychosocial rehabilitation, as
is demonstrated in the following statement: "Work, es-
pecially the opportunity to aspire to and achieve gainful
employment, is a deeply generative and reintegrative
force in the life of every human being" and, as such, it
"must underlie, pervade, and inform" all of the activi-
ties surrounding rehabilitation (19, p. 67).
It must be noted, however, that the vocational em-
phasis in psychosocial rehabilitation is not limited to
the pursuit of full-time or competitive employment. For
some long-term mentally ill persons the notion of work
must be more broadly defined (25-27). Jones, who or-
ganized the excellent, but now superseded, Boardwalk
program in Denver, has expressed the need for such
flexibility in her statement that work opportunities for
long-term patients "should address a variety of skills
and interests and a variety of physical demands ... in
part because different people have different talents .. .
[and in part] because the effects of the illness vary con-
siderably" (28, p. 53). Similarly, van Weeghel and Zeelen
have suggested that "vocational rehabilitation does not
refer to the regular job market as a single final objective
for everybody, but is above all a process with variable
elements and differing results" (23, p. 4).
In this connection, supported employment opportu-
nities, which use personal job coaches to provide sup-
port to workers and to ensure job backup to employers
(29), are important aspects of many psychosocial reha-
bilitation programs.
Sixth, although psychosocial rehabilitation efforts
generally place considerable emphasis on vocational
pursuits, this represents only one area of their involve-
ment (30). The field generally views its mission as
reaching beyond work activities to encompass a full ar-
ray of social and recreational life concerns of mentally
ill people. Thus, it is not uncommon for psychosocial
rehabilitation agencies to sponsor social clubs and to
offer resocialization programs and training in social
skills. They also frequently provide case management
services, as well as various kinds of residential pro-
grams, educational activities, community support inter-
ventions, consumer-run drop-in centers and businesses,
and even family education and support programs (11,
19, 24, 31-35). In short, psychosocial rehabilitation is
at heart oriented toward the comprehensive care of in-
dividuals with long-term mental illnesses.
Seventh, psychosocial rehabilitation requires that pa-
tients be actively involved in their own care and, indeed,
in the very design of their own rehabilitation protocols.
Thus, in the words of Anthony et al. (10, p. 74), the
patient's own "values, experiences, feelings, ideas, and
goals" shape the direction of treatment planning during
all phases of a rehabilitation intervention. In turn, this
requires that the patient be completely informed about
the nature of his or her illness, its symptoms, its course,
and its possible consequences.
Such an emphasis on patient involvement stands in
1457
 PSYCHOSOCIAL REHABILITATION AND PSYCHIATRY
direct contrast to interventions and treatments that do
"to" or "for" patients, instead of giving them the scope
to do "to" or "for" themselves. Peterson, a former pa-
tient who has written about his experiences as a mem-
ber of the renowned Fountain House program in New
York City, has expressed this distinction clearly and
forcibly in a simple but revealing statement: "For me
rehabilitation is not having something done to me" (36,
p. 49). Some rehabilitation programs actually go so far
with the concept of patient involvement that they are,
in effect, consumer-run-and sometimes even con-
sumer-directed-efforts (3 7).
Eighth, psychosocial rehabilitation is not a one-time-
only kind of intervention. It is an ongoing process that
must continue over time, and it is conducted in the vari-
ous settings in which patients find themselves. Hence,
rehabilitation programs, although viewed by many per-
sons as having an essential community focus, may also
be provided in hospital-based settings; the "where" of
a rehabilitation effort is less important than what oc-
curs in a given program and how long that program will
be available to the patient (2, 12). Psychosocial rehabili-
tation is, in short, firmly wedded to the concept of con-
tinuity of care (38), a focus that is buttressed by several
theoretical underpinnings.
First, there is a strong emphasis on the fact that men-
tally ill persons exhibit different functional deficits in
different social environments. It follows that changes in
the external circumstances of these individuals will re-
quire ongoing modifications in their basic rehabilita-
tion protocols and that interventions will have to be
persistent and flexible (12).
In addition, there is evidence that mentally ill per-
sons generally find it difficult to transfer learned skills
and behaviors to new situations (12). Psychosocial re-
habilitation must thus "operate on the principle that
generalization does not just occur; it must be planned"
(10, p. 74).
Moreover, the vulnerabilities of people with long-
term mental illnesses are not time limited (unpublished
1990 paper of J.W. Louwerens). To the contrary, they
are often lifelong and so require continuing interven-
tion. (The implications of enduring disability for the
care of long-term mental patients will be examined
more fully in the discussion that follows.)
These eight basic elements of psychosocial rehabilita-
tion, when considered together, suggest that the disci-
pline is, both in theory and practice, prepared to con-
sider and respond to the interaction of a multiplicity of
biological, psychological, and sociological factors as
they influence the life of a mentally ill individual (31).
Thus, psychosocial rehabilitation may be understood to
favor a distinctly biopsychosocial approach (39) to the
care of people with long-term mental illnesses.
TI-IEORY VERSUS PRACTICE
It is, however, important to note that these theoretical
guidelines are not always observed in practice. There is
1458
sometimes a gap between the real and the ideal, just as
there may be in the practice of psychiatry with long-
term mental patients (40). My own observations during
site visits to numerous psychosocial rehabilitation pro-
grams throughout the United States have led me to con-
clude that a few of them are so extremely antimedical
and antipsychiatric in their outlook that they are, in my
judgment, quite dangerous for the patients enrolled in
them. These programs strongly resist the use of medica-
tions for severely mentally ill individuals and tend to
regard the involvement of medically trained personnel
as something to be avoided at all costs. In fact, some-
times these efforts are not limited to antimedical senti-
ments; they are also more generally antiprofessional, in
that they seem to regard clinical training as something
that takes the humanity out of patient care (7).
On a more positive note, it appears to me that such
blatantly antiprofessional programs have been decreas-
ing in number. Apparently, an acknowledgment that ill-
ness-real illness-underlies psychiatric disability (41)
is growing, perhaps in part as the result of the increas-
ing visibility of untreated mentally ill people who now
live on the streets. However, some of the biased pro-
grams have survived and have unfortunately given psy-
chosocial rehabilitation a bad name. That is why it is
extremely important for the field to define precisely what
psychosocial rehabilitation is-and also what it is not.
Somewhat less abusive than these blatant denials of
illness, but still in my judgment far too antitherapeutic
for comfort, is the existence of unrealistic expectations
of long-term mental patients in some psychosocial re-
habilitation efforts. I have observed a number of in-
stances in which personnel expect mentally ill individu-
als to accomplish tasks that would be unrealistic for
even less disabled persons. I refer specifically to the regi-
mentation that creeps into some programs and virtually
forces mentally ill people always to do something, to
complete something, to go somewhere, or to be some-
where. Of course, rehabilitation is by its very nature
task oriented; that is a given. But it seems obvious that
there must be a limit to the pressure that is placed on
patients to perform.
Another antitherapeutic practice exists in the tend-
ency of some psychosocial rehabilitation efforts to
close their gates-and, more importantly, to close their
consciousness-to the most severely disabled mentally
ill individuals. As a matter of fact, it is not the gate-
keeping per se that is troublesome; few if any programs
fail to exercise some control, however minimal, over
admissions. What is of concern, however, is the exist-
ence of programs that purport to keep no gates but then
proceed to admit only individuals who appear to fit in
with their special offerings-a practice that sometimes
leaves patients who do not fit with no alternatives for
treatment.
Such gatekeeping practices are closely related to still
another difficulty: the tendency of some psychosocial
rehabilitation programs, despite lip service to flexibil-
ity, to place such heavy emphasis on the vocational as-
pects of rehabilitation that other important concerns
Am J Psychiatry 149:11, November 2013

become minimized. Speaking of rehabilitation for
physically disabled persons, Litman (42) cautioned
that, when programs are too focused on vocational ob-
jectives, they may become "dominated by a utilitarian
goal of employability." This systematically discrimi-
nates against persons who are unemployable.
Litman's concern is as valid for psychiatric patients
as it is for physical medicine patients. For one thing,
external economic circumstances, as well as the degree
of competition within the labor force, may severely cur-
tail employment opportunities for mentally ill people
(30; unpublished 1990 paper of J. van Weeghel). Addi-
tionally, the stresses that these individuals sometimes
suffer when their efforts to find work are unsuccessful
may be quite harmful, particularly when competitive
employment is held up as the ultimate goal for every
person.
I mention these issues not because they are intrinsic
to the practice of psychosocial rehabilitation or even
necessarily illustrative of mainstream thought in the
field but, rather, because, when such negative practices
occur, they serve mentally ill individuals poorly. More-
over, these negative practices-these departures from
the ideal-are completely antithetical to the fundamen-
tal philosophy of psychosocial rehabilitation as it is
portrayed in the extensive literature of that field. In
fact, from the point of view of that literature, it may
well be an error to define the efforts that foster such
practices as rehabilitation programs. Yet, in the absence
of a standardized definition of what the field encom-
passes, there is nothing to stop them from identifying
themselves in this way.
On a more positive note, even a cursory review of the
literature suggests that these problems are increasingly
being acknowledged within the field of psychosocial re-
habilitation. This gives us hope for their amelioration.
Lamb (20) has been particularly forthright in identify-
ing these kinds of issues and in cautioning against what
he has termed the "overselling" of rehabilitation. For-
tunately for all concerned, Lamb's writings continue to
have considerable impact on service planning for long-
term patients.
CONCEPTS IN PSYCHIATRIC CARE
One of the most harmful effects of the negative prac-
tices I have described is that they reinforce an impres-
sion that the disciplines of psychosocial rehabilitation
and psychiatry lack a common meeting ground. Is such
a conclusion valid? To answer this question I have se-
lected two major conceptual developments that influ-
ence the psychiatric treatment of long-term mental pa-
tients today (43), and I shall use these as yardsticks for
establishing the degree of fit between the two disci-
plines. I shall first comment on the psychiatric concept
of individualized treatment planning for long-term
mental patients and then examine a psychiatric ap-
proach to the understanding of disability among the
members of this patient population.
Am] Psychiatry 149:11, November 2013
LEONA L. BACHRACH
My choice of the psychiatric concept of individual-
ized treatment planning may perhaps appear gratui-
tous. Does it not go without saying that psychiatric care
will be administered with a focus on the individual pa-
tient? Unfortunately, this has not always been the case,
as is apparent from the frequency with which "dump-
ing" of long-term mental patients has occurred. These
patients have frequently been placed in institutions and
provided, at best, with only stereotyped programming.
What is more, they have often fared no better in their
community placements (44). Indeed, the fact that the
mental patients who need the most comprehensive and
sophisticated care have historically been given the least
individualized treatments has become a source of great
concern to many psychiatrists (40). (I might add that,
as an involved nonpsychiatrist, I believe the future
credibility of psychiatry will rest largely on its ability to
organize individually tailored treatments for long-term
patients as effectively as it has in the past for patients
who are less severely disabled.)
It is encouraging to note, however, that in recent
years the psychiatric literature has shown increasing
concern with the need to accord individualized atten-
tion to long-term mental patients (38, 45). The concept
of individualized treatment planning is now widely
endorsed and forms a potential bridge between the
practice of psychiatry and that of psychosocial rehabili-
tation. As noted earlier, the basic orientation of reha-
bilitation is toward the individual patient-toward
realistically assessing that person's strengths and dis-
abilities and working from there to maximize his or her
potential. Thus, it seems unnecessary to belabor the
point: the fit between psychiatry and psychosocial reha-
bilitation respecting this particular concept leaves little
if any room for theoretical dissonance.
Indeed, the fact that both disciplines speak with a sin-
gle voice on this issue is most encouraging. Whether it
gets its impetus from psychiatry or psychosocial reha-
bilitation, the acknowledgment that programmatic in-
terventions must stress the needs of a mentally ill per-
son, and not the needs of a mentally ill population, is a
major step forward in service planning. It is even possi-
ble that this is the most important advance in service
planning for long-term patients over the past several
decades (45), and the concordance between the two dis-
ciplines in this regard is readily apparent.
The relationship between the psychiatric concept of
disability and the practice of psychosocial rehabilita-
tion is somewhat more complex, although it too sug-
gests considerable congruence between the two disci-
plines. Increasingly today, disability is viewed as having
multiple sources that subsume, but extend beyond, the
direct effects of psychopathology. There have been sev-
eral formulations of this position in the psychiatric lit-
erature, including the focus on impairment, disability,
and handicap that is largely associated with the reha-
bilitation approach of Liberman et al. (15, 16). As a
sociologist, however, I am drawn to the particular con-
structs and terminology used by two British authorities,
Wing and Morris (46).
1459
PSYCHOSOCIAL REHABILITATION AND PSYCHIATRY
Wing and Morris have described three essential varie-
ties of disability that typically affect severely ill long-
term mental patients. The primary disabilities are those
associated with the illness per se; they consist of dys-
functional behaviors or characteristics that may other-
wise be described as symptoms of illness. For example,
people diagnosed with chronic schizophrenia might ex-
hibit such primary disabilities as lethargy, odd and un-
acceptable behavior, a lack of awareness of their handi-
caps, and disturbances in their social relationships. It is
typically the appearance of these symptoms of illness
that leads to diagnosis and, for many individuals al-
though not all, to treatment in the system of care.
Building on the primary disabilities are secondary
disabilities that come not from the illness per se but
from the experience of illness. Wing and Morris have
referred to these as "adverse personal reactions," and
their essence was eloquently captured in an anonymous
patient-authored article that appeared in the American
Journal of Psychiatry several years ago: "Even if medi-
cation can free the schizophrenic patient from some of
his torment, the scars of emotional confusion remain,
felt perhaps more deeply by a greater sensitivity and
vulnerability" (47).
Wing and Morris (46) have suggested that secondary
disabilities may present as much of a problem for suc-
cessful engagement and treatment of the long-term pa-
tient as do the primary symptoms of the illness itself. In
fact, a critical point to keep in mind regarding secon-
dary disabilities is that they are often difficult to over-
come. In Shepherd's words, "a major psychiatric epi-
sode is a frightening and disturbing experience and its
effects may persist long after the primary symptoms
have disappeared" (24, p. 5).
Finally, there is a class of tertiary disabilities that
Wing and Morris (46) call "social disablements." These
come not from the illness per se, nor are they personal
responses to illness. Rather, they are external to the pa-
tient and come from societal reactions to mental illness.
Accordingly, the tertiary disabilities include such cir-
cumstances as diminished social networks, stigma, pov-
erty, unemployment, and the general absence of a place
in society.
A most succinct and moving description of tertiary
disabilities was provided at a meeting in 1987 by a for-
mer mental patient, Essa Leete:
Sadly, in addition to handicaps imposed by our illnesses,
the mentally disabled must constantly deal with barriers
erected by society as well. Of these, there is none more dev-
astating, discrediting and disabling to an individual recov-
ering from mental illness than stigma. We are denied jobs,
unwanted in our communities. We are seen as unattractive,
lazy, stupid, unpredictable, and dangerous.
Inevitably, these societal responses spill over into the
mental health service system and are manifested in pro-
gram offerings for long-term patients that are fre-
quently irrelevant and sometimes downright discrimi-
natory and preclusive.
1460
Lewis, an internist, described the biopsychosocial
perspective as one that "frees us from biologically over-
determined and restrictive criteria and from vague defi-
nitions of disease" (48, p. 262). It is clear that such a
concept is entirely consistent with the psychiatric for-
mulation of disability described here-an approach in
which biological, psychological, and sociological ele-
ments in interaction are understood to give rise to the
problems experienced by long-term mental patients.
Moreover, it seems obvious that such a concept of dis-
ability must also be entirely compatible with the phi-
losophy of psychosocial rehabilitation, which is equally
biopsychosocial. Both suggest that clinical interven-
tions which can affect the lives of long-term mentally ill
people in a positive and lasting way depend on the cli-
nician's ability to respond simultaneously to all their
sources of disability, not just their illnesses (16, 49).
TOWARD A COMMON FOCUS
Given this commonality in outlook, how may the two
disciplines actually share in the clinical care of long-
term mental patients? At the first level of disability-the
level of the primary symptoms-programs that make
the most effective use of pharmacotherapies are needed,
for it is the competent and judicious prescription and
monitoring of drugs that may start the reversal of pri-
mary symptoms and thus allow intervention at the
other levels. Obviously, the medically trained psychia-
trist has a basic role to play with respect to primary
disabilities.
The psychiatrist also has an obvious and essential
role with reference to the secondary disabilities by help-
ing patients to understand, accept, and come to terms
with their illnesses. In fact, psychiatry and rehabilita-
tion can, and should, work together in this regard. They
must make available to each patient a variety of inter-
ventions that will help him or her to respond more re-
alistically to the fact of illness. This includes providing
individual and group psychotherapy, counseling, psy-
choeducation, and, in the most basic way, a full array
of rehabilitative interventions that relate to skills train-
ing, behavioral change, and environmental adaptation.
Areas of overlap between the two disciplines are also
evident with respect to the tertiary disabilities. It is es-
sential that agencies providing services to long-term
mental patients seek to improve overall quality of care,
enhance patients' social networks, minimize the nega-
tive effects of gatekeeping, and attempt to reduce
stigma within the mental health professions and society
at large. Rehabilitation, with its concept of engineering
environmental change, effectively legitimizes the pro-
fessional person's role in these kinds of efforts. Reha-
bilitators, psychiatrists, and everyone else involved in
the care of long-term mentally ill individuals must be
prepared to pressure the service system, from within
and without, to alter its practices and become respon-
sive to the social disablements of these individuals.
The Dutch psychiatrist F.M.J. Woonings, in an un-
Am] Psychiatry 149:11, November 2013

published 1990 paper, defined psychosocial rehabilita-
tion as "a process in which skills are being learned to
cope with permanent disability." At first glance, non-
psychiatrists might regard such a definition-one that
is proffered by a psychiatrist and stresses the perma-
nence of psychiatric disability-as unduly pessimistic.
However, if considered in the context of Wing and
Morris's concept of disability, this definition is entirely
realistic. Since disability is not limited to circumstances
that arise directly from the illness but also includes psy-
chological and sociological elements, and since the lat-
ter may persist independently over time, the notion of
permanent disability is entirely credible. What is more,
it is absolutely consistent with rehabilitation's emphasis
on continuity of care.
UNDERSTANDING THE CONFLICT
The foregoing discussion suggests substantial areas of
compatibility between psychiatric and psychosocial ap-
proaches to the care of long-term mental patients. It is
important to note that there exist a number of clinical
settings in which that compatibility is put into practice
and the two disciplines work together cooperatively
and successfully. Some, like Liberman's programs (15),
actually foster a blurring of the boundaries between the
disciplines. The fact that instances of dissonance are
often sounded loudly does not mean that they necessar-
ily dominate in the relationship between the two fields.
But some dissonance does exist, and as noted pre-
viously, a portion is probably attributable to turf con-
cerns that have become exacerbated by diminishing re-
sources. The fact that it is difficult to know precisely
what a psychosocial rehabilitation program is probably
contributes to the dissonance as well: as we have seen,
some programs that do not honor the philosophy of the
discipline bear that name.
However, there is still another factor that may ex-
plain some of the interdisciplinary conflict. This is the
fact that the comprehensive role of each discipline is
inadequately understood, or perhaps not accepted, by
the other. For example, proponents of psychiatric reha-
bilitation sometimes, and inaccurately, see psychiatry
as following rigid "medical model" practices in the care
of long-term mental patients; they overlook the fact
that the biopsychosocial approach is but one of several
medical models and is particularly supported by psy-
chiatrists who work with this patient population.
Additionally, it is likely that a certain amount of con-
flict is related to the fact that psychosocial rehabilita-
tion has been viewed primarily as tertiary prevention
(16, 50, 51)-as part of a class of interventions that
follow active treatment. It is not surprising that reha-
bilitation practitioners have become somewhat sensi-
tive to this characterization of their work, a view that
they feel, perhaps accurately, has been fostered by psy-
chiatric clinicians and that minimizes their contribution
during the active phases of a patient's illness.
Gittelman (52) has, however, proposed an alternative
Am] Psychiatry 149:11, November 2013
LEONA L. BACHRACH
view, one that establishes psychosocial rehabilitation as
part of secondary prevention-as part of treatment in-
stead of something that follows treatment. This notion,
which is also reflected in the writings of Fine (6), a
prominent occupational therapist, is almost certainly
more in line with psychosocial rehabilitation's existen-
tial view of its mission and is worthy of serious consid-
eration by psychiatrists.
In many ways, however, the controversy over bounda-
ries is basically a meaningless one, a fact that Black rec-
ognized and cautioned against in 1978: "It matters
little whether one considers rehabilitation as part of a
total treatment or mental health approach ... or whether
one thinks of rehabilitation as the totality of the en-
deavor of which the medical and psychiatric treatment
is a part. The fact is that there must be a joining of
resources" (32, pp. 308-309).
REHABILITATION'S INTEGRATIVE FUNCTION
Many rehabilitation practitioners will readily ac-
knowledge that the field of psychosocial rehabilitation
depends on psychiatry in a number of ways. They un-
derstand, for example, that unless the primary symp-
toms described by Wing and Morris are under control,
rehabilitative interventions are likely to have little suc-
cess. They also acknowledge that in the case of illnesses
with episodic exacerbations, it is essential to have
medically trained personnel who are able to sort out
the sources of patient dysfunction. Many also accept
the critical importance of providing psychiatric ther-
apy, individual and group, to long-term mental patients
even as they are enrolled in psychosocial rehabilitation
programs.
But what is the trade-off for psychiatry in allying
itself with psychosocial rehabilitation? I would sub-
mit that, for psychiatry, there is valuable support to
be found in the philosophy, goals, and practice of psy-
chosocial rehabilitation. Psychosocial rehabilitation
is, in essence, an integrative discipline in several differ-
ent senses, all of them important for the practice of
psychiatry.
First, psychosocial rehabilitation is integrative for pa-
tients in a psychological sense, in that it fosters whole-
ness in the individual. When it is pursued realistically
and in a manner consistent with its philosophical foun-
dation, psychosocial rehabilitation enables patients
to develop a sense of hope and purpose that supple-
ments-and may even enhance-more traditional treat-
ment approaches. In this sense, psychosocial rehabilita-
tion supports the goals that psychiatry holds for
patients: to "live, love, and work meaningfully and pro-
ductively in the world" (3). What is more, in the words
of Gittelman and Freedman (53), if psychiatrists fail to
support rehabilitative interventions, they will find
themselves "treating only half the illness."
Second, psychosocial rehabilitation is also integra-
tive for patients in the sense that it assists them in find-
ing their place in the community. With its environ-
1461
PSYCHOSOCIAL REHABILITATION AND PSYCHIATRY
mental focus, psychosocial rehabilitation provides
these individuals with the learning and skills that are
necessary for societal integration. And with its empha-
sis on continuity of care, it helps ensure that those
skills are constantly updated. This is entirely consistent
with psychiatry's aim of enabling mentally ill individu-
als to function optimally in community-based settings.
Needless to say, such societal integration cannot be
complete for all patients, for we are not at present able
to restore all mentally ill persons to full societal func-
tioning. But even for patients whose integration will be
marginal, rehabilitation represents a starting point. At
the very least, it can provide positive experiences and
hope for many people who suffer from long-term men-
tal illnesses.
Third, from the point of view of the psychiatrist who
seeks to reinforce his or her connection with other
medical specialties, having a rehabilitative focus may
serve still another integrative function. Anthony et al.
(2) have shown that there is a close connection between
the essentials of psychosocial rehabilitation and those
of rehabilitation for physically disabled individuals,
and Deegan wrote, "From the perspective of the reha-
bilitation approach, it is no longer necessary to isolate
the psychiatrically disabled as totally different from
other groups of persons with disabilities" (21, p. 11).
Thus, psychosocial rehabilitation offers a tangible
point for consensus and cooperation among medical
specialty groups.
Finally, psychosocial rehabilitation provides an inte-
grative focus for the interdisciplinary care of people
with long-term mental illnesses (2, 17). It is what Grob
described as "a many-sided and multidisciplinary proc-
ess" (51, p. 271), and, as such, it is entirely in keeping
with the goals set forth for community health as they
were expressed in President John F. Kennedy's 1963
statement (9) on a "bold new approach" in mental health
service delivery.
These are too many "integrations" to ignore. The
field of psychosocial rehabilitation is important to psy-
chiatry-and vice versa-for so many different reasons
that it is foolhardy to focus more on differences than on
areas of concordance (54). Whether one considers psy-
chiatric treatment and rehabilitation as two separate
approaches or as two parts of a single approach in pa-
tient care, they need not be viewed as mutually exclu-
sive. To the contrary, psychosocial rehabilitation and
psychiatry can be, and must be, blended, a position that
is underscored by the fact that a number of conscien-
tious and respected psychiatrists-among them, Dou-
glas Bennett, H. Richard Lamb, Robert Liberman, Den-
nis McCrory, Arthur Meyerson, John Talbott, and
John Wing-are themselves deeply involved in the the-
ory and practice of psychosocial rehabilitation.
A recent review of the literature on rehabilitation
outcome supports the notion that psychiatry and psy-
chosocial rehabilitation complement each other's con-
tributions to the improvement of long-term patients'
life circumstances. Although this body of research is
limited by the absence of common definitions and out-
1462
come measures and although its validity is generally
confounded by the interactive effects of psychiatric and
rehabilitative interventions, the existing evidence none-
theless points strongly to the conclusion that both
disciplines must be integrated "to help patients achieve
maximum feasible adaptation" (15, p. 23). I would sub-
mit that, together, these disciplines hold the key to re-
alizing the promise of deinstitutionalization, which
seems largely to have eluded us for the past several
decades.
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