Interview with William Anthony

Executive Director of the Center for Psychiatric Rehabilitation Co-Author (with Director of Training, Marianne Farkas) of A Primer on the Psychiatric Rehabilitation Process

What is the core driving principle of the Primer?

The driving principle is that the process of psychiatric rehabilitation is as important as the program structure (i. e., a program’s polices and procedures) in which psychiatric rehabilitation is practiced. I have had a concern that with the current emphasis on evidence-based practices (e. g. IPS, ACT), that people would forget that psychiatric rehabilitation has an evidence-based process that underlies the evidence-based practices or program structures. The policies and procedures which characterize an evidence-based practice must be complemented by a process that focuses on what happens in the interaction between the people with disabilities and their practitioners. In the late 1970s the Center for Psychiatric Rehabilitation received a series of NIMH grants with a focus on describing and documenting this process, and we have been working on describing, evaluating, training and disseminating the process since then.

What need did you see the Primer fulfilling?

More than ever I believed the field needed a succinct, straightforward presentation of this process to facilitate its use in various rehabilitation programs. We made the Primer a free download in order to maximize its use. It seems easier to change the structure of a program than it is to change how people interact with one another within the program structure. We needed a way to improve the understanding and implementation of the psychiatric rehabilitation process. I hope the Primer does just that.

How did the idea for the Primer first develop?

At various presentations that I was making around the country I was amazed how some of the questions that I received indicated to me a lack of understanding on what the psychiatric rehabilitation process was, its empirical base, and how the process could complement the effectiveness of evidence-based and best practice program models.

Could you expand on how to reconcile evidence-based practices with the people and interaction-based practices you mention?

Essentially the interactions between the helper and the person being helped are helpful in any program structure. No matter the program (e. g., ACT, Supported Employment) the process can help people feel ready to participate, figure out what they wish to achieve, plan what they need to do and have to achieve their goals, and then learn the skills and /or receive the supports that will help them reach their goals.

What are some of the more common misconceptions you’ve encountered?

The most damaging misconception is that people do not understand that there is a strong evidence base to components of the process. In the behavioral science literature there is a good deal of research showing that people are more apt to change: in the presence of a relationship; when they believe themselves ready to change; when they set their own goals; when they are taught new skills; when they feel supported. Some of these components (like the relationship factor) have some of the strongest data supporting them. In this era of evidence-based interventions, the psychiatric rehabilitation process is grounded in a great deal of empirical research.

Where do you believe the field is headed–and how can we prepare?

I think with healthcare reform and the mental health field’s anticipated integration with physical health care, the psychiatric rehabilitation field’s principles and accomplishments will be ignored, especially in specialty care for people with severe conditions such as psychiatric disability, unless we can simply and succinctly explain the process and outcomes we can achieve. Historically the people we serve have not fared well when the field is defined by medical or financial concerns (e.g., deinstitutionalization, Medicaid, Social Security benefit regulations).

How did the Primer’s tracking process develop? Why is tracking so important to overall success?

It sounds redundant, but tracking the process lets you know if you are “on track”! Achieving the outcome that people want may take some time, so by tracking the process people learn “how it’s going”, and that something good is happening even if the outcome goal has yet to be achieved. Simply put, people like feedback on their progress and tracking gives people feedback.

How does principled leadership impact the psychiatric rehabilitation process described in the Primer?

In many agencies implementing the psychiatric rehabilitation process is a change in practice. Organizational change takes leadership, and the text Principled Leadership gives people the important principles of leadership and examples of how current leaders have implemented recovery oriented interventions such as psychiatric rehabilitation in their organization.

When were you first aware of the importance of self-determined goals?

We developed the psychiatric rehabilitation process in the 1970s with a grant from NIMH. When we first piloted the process with persons with psychiatric disabilities the notion of people with psychiatric disabilities determining their own goals was very foreign to the field. We were amazed how the goal setting procedures within the psychiatric rehabilitation process were so easily mastered by people with psychiatric disabilities, and so powerful. It has taken a long time for the mental health field in general to appreciate the importance of self-determined goals in the helping process.

Excerpt from: A Primer on the Psychiatric Rehabilitation Process

Published by the Center for Psychiatric Rehabilitation at Boston University.

We have been practicing, teaching, writing, and/or researching the field of psychiatric rehabilitation for more than three decades. Early in our careers, the psychiatric rehabilitation field we entered had not achieved consensus on its underlying philosophy, had not integrated its research studies into a substantial knowledge base, had few model service programs and sources of funding in existence, had not developed a rehabilitation practice technology, nor articulated the psychiatric rehabilitation process. Gradually over the years, considerable agreement developed on the fundamental philosophy, principles, and values of psychiatric rehabilitation; a significant body of research shaped the knowledge base; funding options increased; a variety of model service programs were created, researched, and disseminated; pre-service and in-service training programs came into existence; a psychiatric rehabilitation technology was increasingly utilized; and the process of psychiatric rehabilitation described.

Importantly, consistent with this progress in psychiatric rehabilitation, recovery from severe mental illnesses became a fact—not a hope. In this recovery era, implementing the process of psychiatric rehabilitation has achieved greater prominence. The process of psychiatric rehabilitation, as this primer will describe, is designed to help people be successful and satisfied in the living, working, learning, and social environments of their choice. The President’s New Freedom Commission on Mental Health (2003) envisioned a future “when everyone with a mental illness will recover and is helped to live, work, learn, and participate fully in their communities”, a phrasing strikingly consistent with the outcomes emphasized in psychiatric rehabilitation. Unique to the psychiatric rehabilitation process is its targeted focus on assisting people to gain or regain valued roles in their communities, as reinforced in the President’s New Freedom Commission report. It is difficult to see how the recovery vision will ever be achieved without wider implementation of psychiatric rehabilitation services.

Recently, the psychiatric rehabilitation field has tended to focus on rehabilitation program models (such as Clubhouse, ACT, IPS) and the program policies and procedures that faithfully guide the models’ implementation. These policies and procedures include such dimensions as the correct mix of disciplines, the place where services are offered, the structure of the work day, etc. In a complementary way, the psychiatric rehabilitation process focuses on the nature of the helping interaction between the practitioner and the consumer that occurs within any psychiatric rehabilitation program model and setting.

However, in order to integrate of the psychiatric rehabilitation process into various program models and to capitalize on its critical role in promoting recovery, there must be a fundamental understanding of the basic psychiatric rehabilitation process and its evidence base. We are amazed at the lack of a thorough comprehension of what the psychiatric rehabilitation process is and is not, and the empirical base underlying the process. Regardless of the name of the program model, the discipline or background of the practitioner, the source of funding or the setting in which people are working, people who help people with severe mental illnesses improve their functioning and gain valued roles in the community should be aware of the essentials of the psychiatric rehabilitation process and how to work with it. Yet uncertainty often reigns about the fundamental process of psychiatric rehabilitation.

We have developed ways to teach providers, including consumer-providers, both the fundamentals and the nitty gritty of the competencies required to deliver the processes. The field continues to confuse brief workshops, overviews, or discussion groups for the intensive training and supervision over time required to change daily practice. Organizational structures, such as job descriptions, record keeping formats, and quality assurance mechanisms often are forgotten when attempting to embed the psychiatric rehabilitation process in an organization so that the process can be delivered reliably over time.

Not ones to give up, A Primer on the Psychiatric Rehabilitation Process is yet another attempt on our parts to clear the confusion. It spells out, in a succinct and straightforward way, the psychiatric rehabilitation process and the underlying content that we and our colleagues at the Boston University Center for Psychiatric Rehabilitation have been developing, demonstrating, teaching, and disseminating. Anyone who works with people with severe mental illnesses in any capacity should be familiar with the process of psychiatric rehabilitation.