Psychiatrists who are working with people with persistent serious mental illnesses will often want to include rehabilitation as part of their patients’ treatments. Most commonly the concept is that first the psychiatrist and/or therapist will clinically treat the patient to stabilize their illness and their symptoms and then they will be ready for rehabilitation. Numerous pitfalls exist with this approach including prolonged searches for "readiness", chronic "patienthood" and dependency, decreased self confidence and willingness to take risks to grow, over interpretations of "normal" life as symptoms, settling for disability and its "benefits", ongoing resentments, frustrations and anger, "noncompliance", "survivors" not of illnesses but of the treatment system itself, etc.

I have lived and promoted an alternative approach of the psychiatrist being fully integrated into the rehabilitation program and recovery community along with the person we’re working with, using our skills not as preparation for rehabilitation and recovery but as tools of rehabilitation and recovery. I’ve become one of the very few psychiatrists who’s an active member of rehabilitation agency associations. When I describe my role to these agencies, they’re always interested, but say that their psychiatrists are nothing like me: they’re entirely symptom focused, they treat people as patients, they’re not part of the team, etc. Frequently, they even have groups and role paying around how to talk with your psychiatrist as though psychiatrists are another insensitive part of "them", the outside system. A new case manager at our program complemented me saying she was surprised at how well I talked with a new lady, opening her up, making plans, treating her respectfully since she’s always experienced psychiatrists as bad, distant and insensitive.

I‘ve found that it is true that to be part of a rehabilitation/recovery program, I’ve had to change many traditional ways of working that I had. It is also clearly true that very few psychiatrists have ever had substantial exposure to, training in, or work in rehabilitation/recovery settings. It was entirely missing from my residency education. I have tried to contribute to teaching psychiatry residents about rehabilitation and recovery in a variety of ways and I’d like to share some of my thoughts and experiences.

I’ve begun viewing teaching rehabilitation and recovery as a process analogous to teaching psychotherapy (I realize that this too is a dying, neglected part of psychiatrists’ training today, but I’m just old enough to have been taught to be a psychotherapist and to know it’s different although compatible with and actually synergistic with, being a doctor). The psychosocial rehabilitation model has distinct characteristics of the kind of helping relationship that is desired, predictable paths to recovery, techniques to promote it, and visions of the desired outcomes. (Once again different from, but compatible, even synergistic with medical training).

The kind of helping relationship in the psychosocial rehabilitation model is really quite different from the traditional doctor-patient relationship and probably the most difficult transition for residents to make. The relationship is not centered around a powerful helping professional taking care of, protecting, and helping a weak, vulnerable, damaged patient. It is centered around helping someone with a mental illness define and pursue their own goals and life visions, empowering and educating them to learn to overcome their own illnesses, and encouraging risk taking and growth, learning from natural consequences and failures. It is far more like the role of coach than of doctor. Most of us naturally make this change when we are trying to help a friend or another doctor, treating them as colleagues or collaborators rather than as patients. However, we have been carefully trained not to be "unprofessional" in our daily work. In addition, people with serious mental illness are often very hard for us to view as potential colleagues or friends.

There are also frequently other reasons for not departing from the medical model doctor role. One resident told me she wasn’t yet comfortable enough being a doctor to give it up and besides she just wasn’t comfortable eating lunch with a mentally ill patient. Another one from a foreign country said he didn’t think he could get respect from American people without a strong doctor role. Another one was the 12^th male doctor in his family and had been groomed his whole life to be one.

On the other hand, a medical model role is simply unsuited to building a rehabilitation relationship with many people with serious mental illnesses. Before we seek to further imitate our medical colleagues we should remember how much difficulty they usually have forming working relationships with people with serious mental illnesses. Learning how to treat neurochemical imbalances is in no way adequate to meeting the daily challenges of our work. Once residents do make the change to a collaborate role, which seems to take about 6 months, they describe feeling liberated, more in touch with the reasons they became a psychiatrist, closer to the people they work with, and more effective.

The second difficult adjustment is that unlike the medical model where the effective treatment modality is the doctor-patient (or therapist-client) dyad, in a psychosocial rehabilitation program the effective treatment modality is the recovery community itself. The staff, members, volunteers, and other neighborhood participants are all part of everyone’s recovery. Once again this is somewhat analogous to the old psychotherapeutic milieus. The psychiatrist is just one member of the community, although potentially a very important one, and our contact with the member needs to be coordinated with the rest of the team and even the entire program’s community to be effective. As one resident recently put it, he’s been on teams before where several staff each work with the same patient, but never where they actually worked together as they do here. We’re far closer to interchangeable generalists than a multidisciplinary team of specialists. Once psychiatrists leave hospital and university settings, it is rare to find hierarchical medical model teams where the psychiatrist gives orders. Residents should be trained in other team models.

The actual techniques of rehabilitation also require a paradigm shift to use. The process is not one of treating illnesses, while someone else handles the rest of what’s needed. It’s one of helping people in their entirety. One resident said instead of learning how to be a bad social worker, he learned how to be a good doctor. The focus is not on relieving symptoms or suffering, but on promoting personal growth and change. Teaching someone how to use medications to help gain control of their illnesses is often more important than the actual symptom relief. Helping someone find their lost child, getting them SSI, or persuading them to go to a substance abuse program are often more important than assessing their illness.

Once that paradigm shift is made the actual techniques are not that difficult to learn. The essential techniques of psychosocial rehabilitation include: 1) helping someone form a vision of their own recovery, 2) training in goal setting and accomplishment, 3) forming emotional connections with people with severe mental illnesses, 4) treating people with respect, 5) empowering people, 6) giving hope, 7) teaching self- management of illnesses, 8) various in-vivo skills training and modeling, 9) social network building, and 10) community integration. They are generally not taught in psychiatric residency programs. Nonetheless, they are very helpful to the people we work with.

The outcomes of our work are another important focus. Most residents are very discouraged in their work with people with serious mental illnesses. They’ve predominately been exposed to either revolving-door hospital patients or medication maintenance clinics aimed at prolonged stabilization. One is frustrating and the other stagnating. In a rehabilitation setting, residents can share people’s recoveries first hand. Dramatic quality of life improvements occur regularly and hopefulness and job satisfaction builds. Residents who work in community settings as part of their residency repeatedly choose careers working in those settings. Careful, long term, longitudinal studies of outcomes of schizophrenia repeatedly are more hopeful than we are. This is especially true when quality of life outcomes are used instead of strictly clinical outcomes. We want residents to evaluate their work on if people have improved quality of life, increased community integration, increased self management of illness, and increased productivity and role performance. Once again, we’re trying to help people, not just treat illnesses.

In conclusion, I have tried to present and teach a comprehensive view of psychosocial rehabilitation. I see it not as an adjunct to clinical treatment, but as an integrating model. It includes a clear vision of the therapeutic relationship, techniques, and desired outcomes in a far more relevant and meaningful way than a strictly medical model for people with serious mental illnesses. As such it deserves to be included as an important part of psychiatric residents’ training.