International Review of Psychiatry, April 2010; 22(2): 114–129

Psychiatric rehabilitation interventions: A review

MARIANNE FARKAS & WILLIAM A. ANTHONY

Center for Psychiatric Rehabilitation, Boston University, USA

Abstract
Psychiatric rehabilitation has become accepted by the mental health field as a legitimate field of study and practice. Over the
last several decades various psychiatric rehabilitation programme models and procedures have been developed, evaluated
and disseminated. At the same time the process of psychiatric rehabilitation has been specified and its underlying values and
practitioner technology articulated. This review describes the psychiatric rehabilitation process and in so doing differentiates
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psychosocial interventions that can be classified as psychiatric rehabilitation interventions from other psychosocial
interventions. Furthermore, the major psychiatric rehabilitation interventions are examined within a framework of the
psychiatric rehabilitation process with a review of their evidence. The review concludes that psychiatric rehabilitation
interventions are currently a mixture of evidence-based practices, promising practices and emerging methods that can be
effectively tied together using the psychiatric rehabilitation process framework of helping individuals with serious mental
illnesses choose, get and keep valued roles, and together with complementary treatment orientated psychosocial
interventions, provide a broad strategy for facilitating recovery.
For personal use only.

Introduction (e.g. Anthony et al., 2002; Farkas & Anthony,

The mental health field has accepted psychiatric
rehabilitation as one of the preferred methods for
helping individuals with serious psychiatric disabil-
ities (Anthony, Cohen, Farkas, & Gagne, 2002;
Rossler, 2006). Nevertheless, it remains less clearly
understood or effectively practiced due in part to the
fact that many types of mental health practitioners,
including psychiatric rehabilitation practitioners,
deliver psychiatric rehabilitation. In addition, rele-
vant research and conceptual articles appear in a
wide range of professional journals. The terms
‘psychosocial interventions’ and ‘psychiatric rehabil-
itation’ have come mistakenly to be used inter-
changeably, a confusion which has led some
researchers to complain that there is no consistent
method to categorize psychosocial treatment (Dixon
et al., 2009). The broad disabilities associated with
mental illnesses cannot be addressed with a single
focused intervention alone. Psychiatric rehabilitation
is a field, not just a series of unique interventions or
programme models. It has a defined set of values,
techniques, programme practices and relevant
outcomes developed over the past thirty years
1989; Pratt, Gill, Barrett, & Roberts, 2007). This
article clarifies psychiatric rehabilitation in its current
context, presents a coherent framework for organiz-
ing psychosocial interventions and reviews the
interventions associated with it.
The individuals who are the focus of
psychiatric rehabilitation
Individuals who are the focus of psychiatric rehabil-
itation services share a diagnosis of mental illness
usually of more than two years duration since
diagnosis and a pronounced limitation in residential,
vocational, social or educational role functioning
(Schinnar, Rothbard, Kanter, & Jung, 1990). Within
this group of people are subgroups, such as young
adults (e.g. Bachrach, 1982; Harris & Bergman,
1987; Pepper & Ryglewicz, 1984), patients from
minority cultures (Ruiz, 1997), patients who are
homeless (e.g. Farr, 1984; Salit, Kuhn, Hartz, Vu, &
Mosso, 1998) or otherwise impoverished (e.g. Ware
& Goldfinger, 1997), older citizens (e.g. Gaitz,
1984), patients with both a severe physical disability
and severe psychiatric disability (e.g. Pelletier,

Correspondence: Marianne Farkas, Center for Psychiatric Rehabilitation, Boston University, 940 Commonwealth Avenue West, Boston, MA 02215, USA.
Tel: 617 353 3549. Fax: 617 353 7700. E-mail: mfarkas@bu.edu
ISSN 0954–0261 print/ISSN 1369–1627 online ß 2010 Institute of Psychiatry
DOI: 10.3109/09540261003730372
 Psychiatric rehabilitation interventions: A review
Rogers, & Dellario, 1985), and patients with
substance abuse problems (e.g. Lehman, 1996; US
Department of Health and Human Services, 1994).
This article uses the terms ‘individuals with serious
mental illnesses’, ‘individuals with lived experience’
or ‘people’ interchangeably with ‘clients’ or ‘con-
sumers’ to refer to the target population. The term
‘individual’ or ‘person’ underscores rehabilitation’s
interest in the human being, across all of his or her
roles (e.g. resident, student, worker, friend).
Individuals who themselves have mental illnesses
use the term ‘lived experience’ (Deegan, 1988) to
emphasize a commonality based on experience,
rather than on labels or the acceptance of any one
explanation of serious mental illnesses.
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Context
In contrast to the practice of psychiatric rehabilita-
tion, service delivery over most of the last century has
generally been heavily influenced by the mistaken
assumption that people with severe mental illnesses
do not recover and, in contrast, deteriorate over time
( Bond et al., 2001; Farkas, Gagne, Anthony, &
For personal use only.
Chamberlin, 2005). There is a growing body of
literature examining the concept of recovery from
mental illnesses and its outcomes (e.g. Anthony,
1993; Davidson, Harding, & Spaniol, 2005; Farkas,
2007; Harding & Zahniser, 1994; Liberman,
Kopelowicz, Ventura, & Gutkind, 2002; Ridgway,
2001; Silverstein & Bellack, 2008; Spaniol,
Wewiorski, Gagne, & Anthony, 2002). People with
psychiatric disabilities have published their experi-
ences of recovery (e.g. Deegan, 1990, 1993; Fisher &
Ahern, 1999; Mead & Copeland, 2000; Ridgway,
2001; Spaniol, Gagne, & Koehler, 1999), and with
like-minded professionals are advocating for system
and agency strategies to facilitate recovery
(e.g. Frese, Stanley, Kress, & Vogel-Scibilia, 2001;
Jacobson & Greenley, 2001; Torgalsboen & Rund,
1998). Clearly, people with psychiatric disabilities
have the same aspirations as any other citizen for
respect and as fulfilling a life as possible. Thirty years
of empirical evidence as well as first person accounts
support the notion that recovery from serious mental
illnesses or the gaining or regaining of a meaningful
life is not only desirable but possible. Recovery is
acknowledged to be the patient’s experience of a
journey from the catastrophic effects of mental illness
to a meaningful life and full citizenship (Deegan,
1990; Farkas, 2007; Ridgway, 2001). Contributing
to this journey and multidimensional outcomes is
now promulgated as the necessary unifying mission
of all mental health services ( Farkas et al., 2005;
New Freedom Commission on Mental Health,
2003).
115
Definition of psychiatric rehabilitation in the
context of recovery
Psychiatric rehabilitation ( PR) is neither a particular
technique nor one intervention but a field and a
service within a mental health system, along with
other services such as treatment services, crisis
intervention services or basic support services.
Since recovery is a consumer experience and not a
programme model or provider practice, no service
can ‘do’ recovery. Psychiatric rehabilitation can and
does promote a vision of recovery or the achievement
of a meaningful life, rather than simply supporting
adaptation or survival in the community
( Farkas, 2007). Typically, recovery outcomes have
included multidimensional variables ranging from as
an increase in physical health and well-being to
gaining or regaining valued societal roles, and
reducing symptoms ( Farkas et al., 2005). Each type
of service within a recovery orientated mental health
system should therefore be able to clearly identify the
recovery outcomes for which it holds itself responsi-
ble. For example, treatment services can contribute to
recovery by reducing symptoms and distress, what-
ever other functions they may perform. In this
context, psychiatric rehabilitation services contribute
to recovery by focusing on outcomes related to role
functioning in ‘real world’ settings chosen by the
individual (Anthony et al., 2002).
Rehabilitation operates at the intersection between
the individual, an individual’s personal network
and the wider social context ( Barbato, 2006).
Rehabilitation, of any kind (i.e. physical, psychiatric,
social, etc.) is ecological (‘person–environment fit’)
and specifically targets improving role performance.
The term ‘psychiatric rehabilitation’ reflects the
focus of this field on people with psychiatric
disabilities and their improved abilities within their
specific preferred role in the ‘real’ world, using the
development of skills and supports as its primary
types of interventions (Anthony et al., 2002;
Farkas, 2006). Without a process committed to
supporting chosen roles and settings, functioning
may be improved but the individual’s vision of a
meaningful life may still not be achieved.
Rehabilitation, therefore, works with social relation-
ships, work, leisure, family life, higher education and
other student pursuits, using interventions that focus
on increasing competencies or skills and providing
environmental supports, rather than focusing on
symptoms and pathology. It does not deny that
symptoms and pathology exist nor the importance of
intervening to reduce these, however its own exper-
tise targets the International Classification of
Impairment, Disability and Handicap ( ICIDH)
dimensions of activity, participation and environ-
ment (WHO, 2001), rather than health.
 116 M. Farkas & W. A. Anthony
The cornerstone of PR interventions is a commit-
ment to a strong partnership between the provider
and the individual receiving services. Psychiatric
rehabilitation values the involvement of individuals
with lived experience in the design, implementation
and evaluation of their own rehabilitation process as
well as services (i.e. ‘Nothing about us without us’).
It uses methods that focus on the person as a whole
rather than on a ‘case’, individualize the process and
its outcomes, promotes self determination, hope and
the importance of choice – all values consistent with
the vision of recovery (Farkas, 2006, 2007). To be
classified a psychiatric rehabilitation PR intervention,
an intervention should, therefore, be based on these
recovery orientated values, while helping individuals
to change (i.e. building skills) or changing the
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environment (i.e. supports) in relation to achieving
a specific preferred role.
Research in psychiatric rehabilitation
The field of psychiatric rehabilitation is still at an
early stage of conducting research on the interven-
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tions that constitute it. While well-executed, rando-
mized clinical trials (RCTs) are considered the ‘gold
standard’ for rigorous research, the limitations of
RCTs, especially in the psychosocial intervention
arena have been well documented (Anthony, Rogers,
& Farkas, 2003; Essock et al., 2003). Limitations
such as small sample sizes available for the complex-
ity of the variables are particularly acute when the
goal is multidimensional, such as recovery, as
opposed to more limited outcomes such as the
prevention of relapse, or re-hospitalization for exam-
ple. Researchers have called for the inclusion of a
broader variety of research designs that are more
consonant with the multidimensionality of recovery
and the state of our current understanding (Anthony
et al., 2003; Essock et al., 2003). A grading scheme
Choosing a valued role
worker/worker/student/
Engaging
Assessing and
Provider
developing readiness
Process
worker/worker/student/
residential/social role
Setting an overall goal
Figure 1. Process framework for psychiatric rehabilitation, person level process.
to assess non-RCT studies has been subsequently
developed to ensure the quality of research
information disseminated in this field ( Farkas &
Rogers, 2007). A review of PR interventions must
therefore take into account the aim of psychiatric
rehabilitation (i.e. improving role performance in a
chosen environment) within the overall mission of
enhancing recovery, the recovery orientated values
which define the strategies used as well as include
both RCTs and non-RCTs as legitimate designs for a
low incidence, complex, ecological field.
A framework for the psychiatric
rehabilitation process and the review
An overall framework known as the psychiatric
rehabilitation approach to serving individuals with
serious psychiatric disabilities was developed at
Boston University’s Center for Psychiatric
Rehabilitation (Anthony, 1979; Anthony et al.,
2002; Farkas & Anthony, 1989). Compared to
well-known programme models in the mental
health field, the psychiatric rehabilitation process
approach is not setting-specific, nor is it tied to a
particular staffing pattern. In contrast to a specific
emphasis with respect to discipline, setting, or service
integration, the psychiatric rehabilitation approach
guides practitioners to develop a personal connection
with individuals with serious mental illnesses to
facilitate, support or teach indiiduals how to choose,
get, and keep a preferred role valued by society
(Anthony & Farkas, 2009). The approach defines the
process both from the frame of reference of the
person served and from the provider’s point of
reference. Figure 1 identifies the major provider
activities that facilitate the different elements of the
choose-get-keep process. Individual PR interventions
can be described in terms of the elements of the
process they accomplish.
Getting a valued role Keeping a valued role
Linking with existing
Assessing critical skill
and/or support
residential/social role
strengths and deficits
opportunities
Person-centred planning
Creating
Developing skills to succeed
in the preferred role
opportunities
Developing supports to
succeed in the preferred role
 Psychiatric rehabilitation interventions: A review
Choosing phase
The choosing process is designed to help individuals
engage as full partners in determining where and in
what role they want to live, learn, work or socialize.
Beginning rehabilitation with this process helps to
establish the individual’s hopes for a future, rather
than beginning with an assessment of strengths and
deficits and then determining a goal that ‘fits’.
Starting with a choice empowers individuals with
serious mental illnesses to take control of their
rehabilitation and ensures that the goals of rehabil-
itation are indeed related to their own vision of their
recovery. Putting the individual receiving services at
the centre of care and supporting that person’s
autonomy is seen as a basic underlying premise
for the provision of modern healthcare in general
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(Grol, 2001; Sensky, 2002). Further, research data
suggests that involving individuals in the planning of
their services improves rehabilitation outcome
(Majumder, Walls, & Fullmer, 1998). While there
is evidence that has shown that offering choice and
shared decision making is more effective than tradi-
tional authoritarian approaches to treatment (Priebe
et al., 2007), the issue of providing choice as a
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cornerstone of rehabilitation is more a question of
rights and full citizenship in society, rather than
simply about evidence. Crawford et al. (2003) note
that several European countries have passed legisla-
tion to ensure that the notions of self determination,
choice and autonomy are translated into action in the
healthcare field.
The major provider components leading to an
individual’s active choice of role and setting in
psychiatric rehabilitation are engagement, readiness
and setting an overall goal.
Engagement
The choosing process is not a simplistic interchange
where the individual simply lists his or her needs and
desires. It involves engaging the person in a partner-
ship. Some engagement techniques used to demon-
strate partnership, caring and respect include
accompanying the person in concrete activities (e.g.
sports or drinking coffee), as well as empathy, which
has long been recognized as a necessary component
of the therapeutic relationship in psychological
interventions with many populations (e.g.,
Anthony, 1993; Anthony et al., 2002; Battaglia,
Finley, & Liebschutz, 2003; Kirsh & Tate, 2006).
Studies report that the individual’s perception of the
relationship is a consistent predictor of improvement
(Bachelor, 1995; Goering, Wasylenki, Farkas,
Lancee, & Ballantyne, 1988). The key to effective
outcomes may well lie with the establishment of an
engaged partnership between the provider and the
117
individual, although the research literature with
respect to the role of relationships or working alliance
and specific outcomes for people with serious men-
tal illnesses is still sparse and in its infancy
(Howgego, Yellowlees, Owen, Meldrum, & Dark,
2003; Lehman et al., 2004).
Readiness
The second critical element of the choosing process
is providing an opportunity for an individual to assess
the extent to which s/he is ready to begin to make a
change. People vary in their willingness to confront
change of any kind, including the types of changes
implied in the psychiatric rehabilitation process
(i.e. gaining or improving a valued role in society)
(Farkas, Sullivan-Soydan, & Gagne, 2000b). The
process may challenge people to make behavioural
or lifestyle changes. Changing from one role
(e.g. hospital patient) to another (e.g. university
student) may require a person to process many
changes simultaneously (e.g. change in identity,
social relationships, level of energy expended daily,
behavioural changes). The readiness to face the
reality of making a decision about the future
(i.e. job, school, home, friends) and finding the will
to do whatever it takes to make that choice can be
overwhelming, but is not immutable. Readiness is a
condition that changes as internal and external
factors change. Prochaska and colleagues have
developed a model for readiness for change
that provides guidance in helping a person
understand their current stage of readiness
(i.e. pre-contemplation through action and mainte-
nance) (Prochaska, DiClemente, & Norcross, 1992).
Farkas, Cohen, McNamara, Nemec, and Cohen
(2000a) developed methods to facilitate the individ-
ual’s own assessment of various factors (i.e. need for
change, commitment to change, their self- and
environmental awareness and preference for close-
ness) related to the stages of readiness and then to
identify the necessary next steps.
Developing readiness for those who are not
prepared to make changes or are very unsure about
their current readiness can involve various strategies,
depending on the readiness factors that are holding
the individual back. For example, techniques such as
motivational interviewing (Miller & Rollnick, 2002)
have been shown to be effective in improving
commitment to change (Hettema, Steele, & Miller,
2005). Programmes where people with serious
mental illnesses are members of a social group
whose functioning depends on their performance of
certain tasks, such as Fountain House clubhouses
(Beard, Propst, & Malamud, 1982; McKay et al.,
2006), can also be effective in promoting a sense of
connection or support ( Norman, 2006) and task
 118 M. Farkas & W. A. Anthony
orientation ( Yau, Chan, Chan, & Chui, 2005)
among other factors, that in turn can lead to a
greater sense of readiness to make changes ( Farkas
et al., 2000b). In addition, success at small but
important tasks in a clubhouse environment can
increase a sense of self-efficacy which also contri-
butes to a greater commitment to change.
Educational seminars about mental illnesses and
the possibilities of recovery and support from peers
who can serve as role models, are additional
techniques that have been used to increase readiness
for change (Cohen, Anthony, & Farkas, 1997;
Cohen, Forbess, & Farkas, 2000). Peer support has
been found to improve a sense of self-efficacy in one
of the first RCTs done on peer support groups
(Castelein et al., 2008).
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Setting an overall goal
Setting an overall goal specifies the preferred valued
role and setting, an initial and critical part of
rehabilitation driving the rest of the process. These
personally meaningful goals provide the framework
for the later identification of critical skills and
supports that will be needed for success and satis-
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faction, for example, as a part-time carpenter, a
student at the local community college or the
treasurer for a local club. To set such a goal, a
provider can facilitate individual identifying personal
criteria for making a decision; researching alterna-
tives and using a structured problem solving method
to select the role and setting the person wants to
achieve over an 18-month to two-year period
(Anthony et al., 2002; Cohen, Farkas, Cohen, &
Unger, 1991). This overall goal motivates the indi-
vidual by setting a meaningful target to achieve,
linked to his/her personal vision of what recovery
would look like. In a randomized clinical trial using
Boston University’s technology for training providers
to set overall rehabilitation goals (Cohen et al.,
1991), Shern et al. (2000) compared experimental
participants who were homeless, street dwelling and
mentally ill, to a similar group who received standard
treatment. Participants in the psychiatric rehabilita-
tion condition where the collaborative goal setting
process was emphasized spent less time on the streets
and more time in community housing. Supported
employment (Drake et al., 1994) and supported
education (Mowbray, Brown, Sullivan-Soydan, &
Furlong-Norman, 2002) are rehabilitation interven-
tions which rapidly place the individual in compet-
itive employment or normative educational
programmes (e.g. high school, university, appren-
ticeship) and then provide support and training to
keep the person in that role. While not designed for
this purpose, concrete, real world experiences gained
in interventions such as transitional employment
within the Fountain House model, supported
employment or supported education also can be
helpful to the individual in providing a better
understanding of what is personally important,
especially for those with little work or school history.
These personal criteria are critical to the person’s
ability to identify meaningful long term school or
career goals.
In addition to identifying clear personal criteria for
making a choice, people need a structured
problem-solving method to come to a decision
about their goals. Shared decision making, one
such popular method, is essentially a negotiation
between the provider and the individual, based on
education about options and consequences ( Deegan,
Rapp, Holter, & Riefer, 2008). A recent review of the
literature in shared decision making in medical
practice suggested that such tools can be effective
to increase engagement and satisfaction with services
( Joosten, et al., 2008).
Shared decision making has also been suggested as
useful for rehabilitation goal setting ( Drake et al.,
2009b), however, such an application does not
correspond to the values of self-determination in
recovery and rehabilitation. While some decisions,
like medication choices should be shared, decisions
about goals are truly personal statements of meaning
and future hopes. These do not lend themselves to
negotiated solutions, but rather to techniques that
assist the person to make a well informed choice
followed by targeted rehabilitation interventions to
achieve the demands of the selected desired roles.
Getting phase
The getting process involves intervening in the
environment to help people link with opportunities
that exist or to help create more opportunities in
order to obtain the roles they want. One major
barrier to getting a job, housing, education or a social
environment is stigma. Numerous studies have
examined the role of stigma in diminishing access
to societal opportunities for individuals with serious
mental illnesses, as well as the negative consequences
of labelling on the individual (e.g. Corrigan, Green,
Lundin, Kubiak, & Penn, 2001; Gaebel, Baumann,
Witte, & Zaeske, 2002; Jorm, 2000; Lauber, Nordt,
Falcato, & Roessler, 2004; Link, Struening, Rahav,
Phelan, & Nuttbrock, 1997; Mueller et al., 2006).
Interventions designed to reduce stigma can be
categorized in three strategies: education, contact
and protest. Even though programmes that target
specific groups (e.g. students, or police) do appear to
strengthen educational anti-stigma programmes
(Corrigan & Penn, 1999; Holmes, Corrigan,
Williams, Canar, & Kubiak, 1999; Pinfold et al.,
2003), it is generally agreed that education alone is
 Psychiatric rehabilitation interventions: A review
not enough (Stuart, Arboleda-Florez, & Sartorius,
2005). Strategies involving contact between people
with lived experience and others provide a personal
experience of those with mental illnesses, breaking
down stereotypes and countering negative beliefs
( Vaughan & Hansen, 2004). In a review of the
research on contact, Couture and Penn (2003),
conclude that contact has positive effects, especially
with respect to reducing the stigma due to perceived
dangerousness, fear and social distance. A strong
argument in favour of psychiatric rehabilitation’s
focus on ‘real world’ settings and socially valued
roles is the positive impact that contact between
those with and without psychiatric disabilities has on
reducing social distance ( Lauber et al., 2004). The
third method, social protest (Corrigan &
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Penn, 1999), has had only mixed results.
Interventions that include education, contact and
the development of the commitment to action by a
specific group or groups have been suggested as the
most powerful stigma reduction strategy (Pinfold,
Thornicroft, Huxley, & Farmer, 2005).
Obtaining a valued role in the community involves
more than reducing stigma. It also involves increas-
ing the number of settings and opportunities. There
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is a growing body of sound research studies
( Barbato, 2006) demonstrating the significant role
that social and environmental risk factors play in
maintaining psychiatric disabilities, such as migra-
tion and urban living, among others (Cantor &
Selten, 2005; van Os, Hansen, Bijl, & Vollebergh,
2001). Research has only begun to be done on
strategies such as community development, advo-
cacy, and job development in terms of their use in PR
to overcome these risk factors and other barriers in
order to provide more opportunities. One example of
such research is a recent multi-site randomized
clinical trial found that individuals who received job
development services were five times as likely to
get competitive employment as those who did not
(Cook et al., 2008).
Keeping phase
Assessing and planning. Keeping valued roles is the
third critical component of the psychiatric rehabili-
tation process. The keeping process is based on the
principle that improving skills and/or supports crit-
ical to functioning in the person’s chosen role leads
to success and satisfaction. For example, if the
chosen role is that of a part-time cleaner in an
office building, the skill of ‘evaluating task comple-
tion’ may be critical, while perhaps interpersonal
skills are not as important. Cleaning supplies and
transportation to the job may be critical resources. If
the chosen role is that of a room-mate in a rented flat,
the skill of ‘evaluating task completion’ may be
119
irrelevant, while the skill of ‘negotiating conflict’ may
be critical depending on the roommate’s specific
characteristics. Having money for rent is a critical
resource, while having transportation may not be.
Standardized functional assessments and checklists
unfortunately do not permit the individualization and
specificity relative to environmental demands that are
necessary to devise appropriate rehabilitation
interventions ( Farkas, O’Brien, Cohen, & Anthony,
1994). Interventions need to be planned to overcome
the specific skill and resources assessed both as
deficits and critical to the valued role selected in the
choosing phase.
Skill development interventions
The evidence that people with serious mental illnesses
can learn skills is robust ( Dilk & Bond, 1996;
Kopelowicz, Liberman, & Zarate, 2006; Kurtz &
Mueser, 2008). Social skills training (SST ) is perhaps
the best known skills training method ( Bellack, 2004;
Kopelowicz et al., 2006; Liberman, 1998). The
content of the SST modules includes both treatment
orientated training programmes (e.g. medication
management, substance abuse management)
( Wallace, Liberman, MacKain, Blackwell, &
Eckman, 1992) and rehabilitation orientated pro-
grammes (e.g. community re-entry and work-place
fundamentals) (Liberman et al., 1998). Studies have
been conducted in diverse treatment settings, by
diverse practitioners covering a defined set of skills
(e.g. Bellack, 2004; Heinssen, Liberman, &
Kopelowicz, 2000; Xiang et al., 2007). Kurtz and
Mueser (2008) report significant effects on role play
tests as well as measures of community functioning,
concluding, however, that the number of studies that
include follow-up data is too small to be confident
about the durability of these effects. Based on the
preponderance of the evidence, Dixon et al. (2009)
recommend that individuals with schizophrenia with
deficits in skills needed for everyday activities should
be offered skills training that is supplemented with
strategies for ensuring adequate practice in applying
these skills to everyday life.
Most skills training, however, including SST, puts
participants in a passive role where they are recipients
of reinforcers and information designed to help them
perform behaviours, that providers or significant
others deem important ( Ellison et al., 2002; Shern
et al., 2000). The Center for Psychiatric
Rehabilitation designed a method called direct skills
teaching (DST), that systematically incorporates
basic educational and cognitive techniques so that
providers can outline the knowledge needed to learn
any relevant skill, develop a structured lesson plan to
teach each component behaviour and involve the
person and individuals in the relevant environment
 120 M. Farkas & W. A. Anthony
in practice and generalization efforts (Cohen,
Danley, & Nemec, 1985b). DST partners with the
learner to ensure that only critical skills necessary for
functioning in the specific preferred role (rehabilita-
tion goal), and assessed as missing from the person’s
repertoire, are taught. DST is part of an overall PR
promising practice (Rogers, Anthony, & Farkas,
2006) and can be used to modify existing SST in
order to increase its congruence with the rehabilita-
tion process of choose-get-keep. Modifications such
as preparing for SST by identifying an overall
rehabilitation goal, only teaching the assessed critical
skills for that goal and modifying the lessons to reflect
a teaching process which involves the learner in a
partnership, can enhance SST as a rehabilitation
intervention.
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The problem of generalization in social skills has
remained a thorny one. Emerging strategies seem to
be converging on the principles of direct skills
teaching (Cohen, Ridley, & Cohen, 1985a). They
suggest, and research has confirmed, that facilitating
the application of trained skills in everyday environ-
ments is more effective than simply providing
homework practices (Glynn et al., 2002; Xiang
et al., 2007). Strategies such as incorporating
For personal use only.
trainer-guided community-based practice and train-
ing family members or other natural supports to help
with generalization hold promise (Glynn et al., 2002;
Kopelowicz, Zarate, Gonzalez Smith, Mintz, &
Liberman, 2003).
Another type of skill development is the group of
behavioural interventions known as cognitive reme-
diation. Cognitive deficits are common for indivi-
duals with serious mental illnesses and often impede
work, social relationships and independent living
(McGurk, Twamley, Sitzer, McHugo, & Mueser,
2007). Cognitive remediation specifically targets
skills in areas such as memory, attention and
reasoning to improve daily functioning. A recent
meta-analysis of 26 randomized controlled trials of
cognitive remediation including 1,151 subjects with
schizophrenia, concluded that these techniques pro-
duce moderate improvements in cognitive perfor-
mance which, when combined with psychiatric
rehabilitation techniques, also improve functional
outcomes (McGurk et al., 2007), such as employ-
ment (McGurk, Mueser, DeRosa, & Wolfe, 2009).
While identified as a promising practice, Dixon et al.
(2009) consider current data on cognitive remedia-
tion as sufficient to build further research but not yet
sufficient to make concrete, evidence-based clinical
recommendations about its use at this time.
Support interventions
PR support interventions typically involve the use
of people, objects, locations or activities that
accommodate the individual’s lack of skill, so that
this gap does not result in the person being unable to
perform successfully in his or her chosen role. For
example, a person who cannot remember appoint-
ments may use a wrist watch that buzzes at the time
of the appointment as a reminder. Someone who
cannot drive or use public transportation may use a
relative or friend to drive them to school.
Case management interventions help individuals
obtain and use the supports they want and need.
Rehabilitation case management links people with
mental illnesses to resources that will help them to
achieve the specific valued role they seek. The
strengths model of case management (SMCM)
(Rapp & Wintersteen, 1989) and the person centred
rehabilitation case management (PCRCM) approach
(Cohen, Forbess, & Farkas, 1988) focus on strengths
to achieve effective links with resources involve
individuals as partners in the process and are most
congruent with the values of psychiatric rehabilita-
tion. While these have been well disseminated and
reviewed (Anthony et al., 2002), the assertive com-
munity treatment programme (ACT ) developed by
Stein and Test (1980) has been the most investi-
gated. Based on the evidence, the Patient Outcomes
Research Team (PORT ) psychosocial treatment
recommendations recommend the use of ACT
particularly for those who are homeless or who are
at risk for repeated hospitalizations ( Dixon et al.,
2009). ACT appears to have a positive impact on two
rehabilitation outcomes: increased tenure in stable
community housing (e.g. Essock & Kontos, 1995;
Lehman, Dixon, Kernan, DeForge, & Postrado,
1997; Nelson, Aubrey, & Lafrance, 2007) and more
recently, employment outcomes. Studies indicate
that when individuals are randomized to ACT teams
with employment specialists, they are more likely to
have paid employment, be working in competitive
employment and are employed for longer periods of
time than those in standard treatment (Chandler,
Hu, Meisel, McGowen, & Madison, 1997;
McFarlane et al., 2000). ACT seems to be most
relevant to the USA; however, since its outcomes
outside the USA have been shown to be question-
able, particularly in countries with integrated service
systems (Burns et al., 2007b; Sytema, Wunderlink,
Bloemers, Roorda, & Wiersma, 2007). Furthermore,
unlike the SMCM and PCRCM, the ACT model
seems to promote some values that are not recovery
or rehabilitation orientated. For example, its assertive
outreach can become coercive in the way in which it
is implemented and choice is further diminished in
that individuals must work with a team, even if
they prefer the privacy of working with one worker
(Drake & Deegan, 2008).
Besides professional support, support can also be
given by non-professionals. Of individuals with
 Psychiatric rehabilitation interventions: A review
mental illnesses, 50–90% live with their relatives
following acute psychiatric treatment (Schulze &
Rossler, 2005). The most well-known family support
interventions are psycho-education group interven-
tions which typically use education and support to
target outcomes for the family care givers themselves
(e.g. McFarlane, McNary, Dixon, Hornby, &
Cimett, 2001; Pickett-Schenk et al., 2006a), or for
the individuals with serious mental illnesses. They
have been found effective for outcomes such as levels
of knowledge about schizophrenia, improved
information needs, improved family relationships,
reduced family burden, and improved satisfac-
tion in their caregiver role (Kulhara et al., 2009;
Pickett-Schenk et al., 2006a, 2006b; Pickett-Schenk,
Lippincott, Bennett, & Steigman, 2008). Briefer
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family interventions (less than 6 months) that include
education, training and support may also improve
the functional and vocational status of their family
member, among other outcomes (e.g. Xiang, Ran, &
Li, 1994). While family education programmes may
increase family perceptions of being supported and
thus reduce their sense of burden, not all families are
equally capable of giving full support to their family
member, nor are they necessarily willing to replace
For personal use only.
insufficient healthcare systems (Koukia & Madianos,
2005; Strachan, 1986).
In addition to PR support interventions provided
by case managers and family members, peer support
has been increasingly recognized as a critical com-
ponent of a progressive mental health and rehabili-
tation system. Peer support rests on the belief that
people who have faced, endured, and overcome
adversity can offer useful support, encouragement
and hope to others facing similar situations
( Davidson, Chinman, Sells, & Rowe, 2006). Peers
to date have included a wide range of roles from
serving as members of regular clinical teams such as
ACT, providing peer support specialist services or
running independently operated services of their own
(Goldstrom et al., 2006). Peers can serve as role
models for one another, reducing stigma and
removing barriers to accessing housing, employment
and education. This variety, while providing flexible
vehicles for support, also makes rigorous research
more difficult. While the existing data suggests that
peer support can be positive (Davidson et al., 2006;
Solomon & Draine, 1995), there are very few well
controlled studies of the effects of peer support
( Davidson et al., 2006). Davidson and colleagues
rightly point out that at this early stage of developing
an understanding of peer support, traditional clinical
measures (e.g. rehospitalization, symptom reduc-
tion) are perhaps inappropriate to evaluate peer
services because they may not capture the processes
and outcomes of more innovative peer programmes.
Moreover, since peer support is fundamental to
121
psychiatric rehabilitation values and practice, more
research is clearly needed to ascertain the ways in
which it is effective and the ingredients of its
effectiveness.
Other support interventions are based on the fact
that most people with psychiatric disabilities want
decent housing, meaningful, appropriate education,
a meaningful career and satisfying relationships. The
best known examples of these interventions are
supported employment, supported housing and
supported education. These types of interventions
tend to combine support with some skill
development. The three interventions begin with
the premise that it is better to help people access the
‘real world’ environment of housing, work and
school quickly and provide intensive supports in
those environments, than to spend lengthy periods of
time preparing to enter these settings. All too often
in the past, preparation became a dead end and
individuals languished in sheltered housing,
sheltered workshops and day treatment classes
forever.
There are many models of vocational rehabilitation
which provide support including clubhouses (Beard
et al., 1982), client-based industries and social firms
( Warner & Mandiberg, 2006), representing a range
of options vis à vis the intensity or length of support
and the type of competitive employment reflected in
its usual options. These are promising practices
which focus on providing individuals with experi-
ences and support to do ‘real work for real pay’.
Supported employment, and particularly the indi-
vidual placement and support model (IPS) (Drake
et al., 1994) which integrates clinical and vocational
services, has, however, been the most widely
researched. The most recent schizophrenia patient
outcomes research team (PORT ) for psychosocial
treatments recommends, based on the sufficiency of
clinical trials, that any person with schizophrenia
with a goal of employment should be offered
supported employment, especially IPS (Dixon
et al., 2009). Clinical trials have consistently shown
the viability and effectiveness of supported employ-
ment in a variety of countries and cultures in helping
individuals achieve competitive employment, work
more hours and earn more wages than those who did
not receive IPS (e.g. Burns et al., 2007a; Drake et al.,
1994; Drake, Becker, Biesanz, Wyzik, & Torrey,
1996). The extent of job retention with IPS is unclear
however, with some studies indicating that rapid
entry into employment predicts shorter job tenure
(Catty et al., 2008) or has negative job endings
(Drake & Bond, 2008), while others suggest that over
half of those enrolled in IPS become steady workers
over a ten-year follow-up period (Campbell, Bond &
Drake, 2009). Programmes that implement IPS
without paying attention to the individual’s interest
 122 M. Farkas & W. A. Anthony
in work, have significantly lower employment rates
(Lehman et al., 2002) and about one third of those
who enter supported employment programmes are
unsuccessful finding competitive work ( Drake &
Bond, 2008). Campbell et al. (2009) concede that
reaching out to those who are currently unengaged in
the world of work or who do not express a vocational
goal requires further development of IPS. On
balance, given the promising practices available as
options that do address the unengaged (e.g. club-
houses, social firms) and the strength of the evidence
for IPS, rehabilitation systems should include as
large a range of vocational support models as possible
to avoid the ‘single model trap’ (Kramer, Anthony,
Rogers, & Kennard, 2003).
Supported housing provides people with the pos-
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sibility of living in the type of residences they prefer
in the normal housing market, with flexible support
from a provider or helper of some kind that comes
into the home anywhere from 4 to 25 or more hours
per week as needed and wanted (Anthony et al.,
2002). Supported housing can improve the living
situation of individuals who are psychiatrically
disabled, homeless (Shern et al., 2000) and with
substance abuse problems (Padgett, Gulcur, &
For personal use only.
Tsemberis, 2006). Results show that supported
housing can help people stay in apartments or
homes up to about 80% of the time over an extended
period ( Tsemberis, Gulcur, & Nakae, 2004). In a
systematic review of experimental and quasi exper-
imental studies, Rogers, Cash, and Olschewski
(2008) conclude that the evidence for supported
housing is robust, demonstrating that elements such
as rapid entry into housing with options to choose
from, combined with intensive case management
services and having access to affordable housing with
a well integrated service system, lead to better tenure
and functional outcomes.
Supported education for individuals with severe
mental illnesses, pioneered by the Center for
Psychiatric Rehabilitation (Anthony & Unger, 1991;
Hutchinson, Kohn, & Unger, 1989), provides the
services necessary to help individuals access and
complete integrated post-secondary educational
programmes, rather than segregated or specialized
settings, so that they can achieve their educational
goals. Rogers, Cash-MacDonald, Brucker, and Maru
(2009) comment, in their systematic review of
supported education research, that there are very
few well-controlled studies of supported education
(e.g. Collins, Bybee, & Mowbray, 1998; Mowbray,
Collins, & Bybee, 1999). Evidence from existing
studies suggests that individuals with significant
psychiatric disabilities can enrol in and pursue
educational opportunities in integrated settings in
the community, such as high schools, community
colleges, universities or apprenticeship training
programmes (Collins et al., 1998), while other
preliminary but insufficient data indicates that
supported education may increase the educational
attainment of individuals with psychiatric disabilities
(Mowbray & Collins, 2002; Rogers et al., 2009).
In many industrialized countries access to higher
education or post-secondary training is considered to
be a right of all citizens with the academic or skill
qualifications. For this reason alone, more research
should be done to add to our preliminary under-
standing of the effectiveness of supported education
as a viable method of improving educational success.
Complementary interventions
The choosing-getting-keeping valued roles frame-
work helps to sort out those interventions which
support the psychiatric rehabilitation process, as
compared to those which may use psychosocial
tools but are not involved in helping individuals
choose, get or keep a specific valued role. The use of
psychosocial interventions focused on the reduction
of symptoms and effects of the illness itself and that
are congruent with recovery and psychiatric rehabil-
itation values of person orientation, partnership, self
determination and hope, while not PR interventions,
can be well used in complement with PR to provide
comprehensive overall approaches to recovery.
Examples of such complementary psychosocial inter-
ventions are shared decision making about medica-
tions ( Deegan et al., 2008), illness management and
recovery (Mueser et al., 2006) and wellness action
recovery planning (Copeland, 2002).
Implementing psychiatric rehabilitation
As is evidenced in this review, psychiatric rehabili-
tation currently consists of a combination of prom-
ising practices and those with sufficient RCTs to
qualify as evidence-based practices that focus on
helping people achieve a valued role they want, in
society. While a detailed discussion of the problems
arising when attempting to put PR into practice is
outside the purview of this article, several common
problems can be summarized. These include an
overreliance on practices supported by RCT findings
or evidence-based practices, and a confusion of
implementation methods and goals and incomplete
plans for implementation.
In the USA and some other countries, systems
level policies are beginning to support only those few
interventions that currently have built up evidence
through many RCTs. As this review suggests, PR has
many more interventions based on rigorous, but
non-RCT studies than RCTs, due in part to the
relatively low incidence of the population coupled
with the multidimensional, ecological factors
 Psychiatric rehabilitation interventions: A review
inherent in PR (Farkas & Rogers, 2007). While RCT
evidence must be included, both the state of our
current knowledge base and the need to transform
service delivery require that the PR field consider not
only the evidence for a particular practice but also the
value base associated with it, in order to create a
system congruent with the overall mission of
recovery (Farkas & Anthony, 2006). As interventions
leave the realm of science and begin to influence
national policy and the politics of service delivery, it
is important to be wary about overreliance on
evidence-based practices which can lead to a single
model service system or the exclusion of meaningful
promising practices. Brown, Brown, and Sharma
(2005) emphasize that it is the value base of an
intervention and the perceived quality of life
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impacted by an intervention that, in the final analysis
provides a better measure of the overall merit of an
intervention to the individual. Best practices which
can transform a service system can be defined as
those practices that have a recovery value base
(i.e. person orientation, self-determination, partner-
ship, hope) and the best available evidence with it,
which may or may not be RCTs.
Some evidence-based practices reviewed in this
For personal use only.
article can be used within the choose-get-keep PR
framework, with the few caveats discussed in the
article (e.g. supported housing, supported employ-
ment); some require modifications (e.g. social skills
training, ACT ) to enhance congruence with recovery
orientated values to create a rehabilitation best
practice. Some promising practices and current
value-based interventions, important to PR practice
and perceived as meaningful at the patient and family
level (e.g. supported education, peer support),
require more research to establish a greater evidence
base. An effort to incorporate PR at this stage of the
field’s development requires the use of an array of
those interventions with the best available evidence
and the most congruent with recovery orientated
PR values, rather than simply those with the
most RCTs.
Implementing best practice in PR is a difficult
endeavour. Barriers to effective implementation or
knowledge translation include problems such as a
confusion of methods and goals, for example, which
can lead to using methods designed to increase
awareness and understanding of information even
though the goal is a change in practice, for example
(Farkas, Jette, Tennstedt, Haley, & Quinn, 2003;
Sudsawad, 2007). These commonly thought of
exposure methods (i.e. ‘getting the word out’
through journal publishing or systematic reviews
leading to practice guidelines), have little or no effect
in practice (Shojania & Grimshaw, 2005).
Furthermore, adopting quality assurance or improve-
ment methods which only report on behaviour have
123
produced only modest results (Drake, Bond, &
Essock, 2009a). Introducing PR interventions with
the goal of a change in provider practice or behaviour
require methods that take into account the complex-
ity inherent in changing behaviour over time. Such
expertise and embedding methods focus on system-
atic training of both providers and supervisors,
follow-up supervision of the application of the
newly acquired knowledge and skills, as well as
changes in organizational structure over time, in
order to incorporate behaviour change into
daily practice (Farkas et al., 2003; Farkas &
Anthony, 2007).
Disappointing results in implementing innovations
across many countries in the past have also resulted
from inadequate implementation plans. Inadequate
implementation plans included a lack of clarity about
the interventions themselves; a lack of stakeholder
support; staffing issues and leadership issues that
led to incomplete use of the innovation in prac-
tice, inadequate funding and inadequate coopera-
tion among different services (e.g. Backer, Liberman,
& Kuehnel, 1986; Corbiere, Bond, Glodner, &
Ptasinski, 2005; Farkas et al., 2003; McFarlane
et al., 2001; van Erp et al., 2007).
In distilling the experience of three decades of PR
dissemination in various countries across all con-
tinents excepts Africa, the Center for Psychiatric
Rehabilitation has identified three main categories of
focus important to ensuring a comprehensive imple-
mentation plan for introducing PR interventions:
culture, commitment, and capacity (Farkas,
Ashcraft, & Anthony, 2008). Organizing an imple-
mentation plan that assesses and then enhances
culture involves ensuring that the organizational
structures and ‘ways of doing business’ are consistent
with the spirit and intent of PR and each of the
recovery orientated values inherent in its mission, to
support the use of the intervention being implemen-
ted. For example, user involvement in designing,
delivering and evaluating services is critical compo-
nent of a recovery orientated service culture like PR
(Farkas et al., 2005). Promoting the hiring of
individuals with serious mental illnesses as peer
providers as well as in the role of helping profes-
sionals and administrators reflects a culture of full
partnership. Simple activities such as celebrating
personal successes or inviting peers who have
completed university degrees, have families or hold
jobs, to speak to staff and patients of an agency for
example, can enhance an organization’s culture of
hopefulness. Culture also includes elements related
to the introduction of change (e.g. the extent to
which an organization is characterized by openness
to learning, willingness to entertain challenges and
effective problem solving) (Farkas, 1984, 1990). An
organizational culture of openness to innovation and
 124 M. Farkas & W. A. Anthony
learning provides positive energy for change that
increases the likelihood of implementation
success (Farkas, 1990; Whitley, Gingerich, Lutz, &
Mueser, 2009).
Commitment involves ensuring that all major
actors are willing and able to support the implemen-
tation efforts. Since such efforts typically take from
3 to 5 years or more to embed into daily practice
(Anthony et al., 2002), it is vital that the leaders are
not only enthusiastic at the beginning but remain
fully committed. Difficulties in stakeholder support
(e.g. families, individuals with lived experience,
legislators, funding bodies) often reflect inadequate
attention being paid to these groups when introdu-
cing and embedding innovations. Commitment
begins with dissatisfaction with the status quo, a
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belief in the degree to which resources will exist to
make the change, and a basic level of understanding
about the characteristics and implications of the PR
interventions the organization proposes to
implement (Farkas et al., 2008). Effective PR
implementation requires ensuring the alignment
of commitment among leadership of the critical
stakeholder groups so that financial, political
and community support work in concert to
For personal use only.
ensure implementation of the best practice
( Drake et al., 2009a).
Capacity reflects aspects of implementation related
to staff knowledge, attitudes and skill in delivering
the PR best practice. The Center for Psychiatric
Rehabilitation has developed competency-based PR
training programmes for providers, in specific
choose-get-keep skills that can enhance the capacity
of providers to deliver many of the psychosocial
interventions reviewed. While these interventions
and models currently provide training in the delivery
of their own process and techniques, discrete prac-
titioner competencies to put the techniques into
practice are often missing. Practitioners skills that
can be taught and implemented in the delivery of the
reviewed interventions include for example, how to
assess and develop readiness for change
(Farkas et al., 2000a), how to help people determine
the valued roles they want (Cohen et al., 1991); how
to assess skills and supports relative to the person’s
valued role aspirations (Cohen, Farkas, & Cohen,
1986); how to teach or modify structured skill
programmes to reflect individual needs and how to
promote skill generalization (Cohen et al., 1985b),
among many others. Research reviews indicate
that these skills can be reliably taught and show
promise in their use across a wide variety of
psychosocial programme models and interventions
(Rogers et al., 2006).
In conclusion, psychiatric rehabilitation has come
of age. There are now robust evidence-based
interventions, promising practices and
emerging methods. These can be tied together by
skilled practitioners practising within a process
framework of choosing-getting-keeping valued
roles. When implemented using comprehensive
expertise and embedding methods that pay attention
to the culture, commitment and capacity of organi-
zations, such interventions can help individuals with
the lived experience of serious mental illness achieve
success and satisfaction in the student, worker,
resident, social roles they want and thus contribute
to the individual’s overall recovery.
Declaration of interest: This article was supported
in part by the National Institute of Disability and
Rehabilitation Research, and the Substance Abuse,
Mental Health Administration/Center for Mental
Health Services, grant number H133B090014. The
authors report no conflicts of interest. The authors
alone are responsible for the content and writing of
the paper.
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