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by Dr. Susan McGurk and Dr. Kim Mueser

We are constantly barraged in our daily lives with new information competing for our limited attention. And there is even more information available than ever before, at the tip of our fingers, on our cell phones and computers. We need to manage the beckoning alerts of tweets, beeps, pings, and other sounds our devices make to inform us something “important” has happened (such as receiving a cell phone text) or try to be mindful of the accumulation of unanswered messages, posts, and other communications whose arrival we have allowed to go unannounced. Our computers and cell phones are a minefield of emails, prompts, and the bottomless pit of the internet, promising infinite information without protection from the perils of endless distractions. Even the mere presence of your (turned-off) cell phone can drain your attention. It is not surprising then, that we often end our day feeling mentally exhausted but without completing the tasks that we need to get done.

Although attention is a keystone thinking skill and a precious, limited resource for managing information, it is just one of several cognitive domains that serve us in our day-to-day lives. We also need to learn and remember information, plan ahead, solve problems, and think on our feet. One other often neglected, but critical thinking area is self-thinking. Negative thinking can adversely impact our confidence and effort to achieve what we want to. We need skills to enhance our awareness of such thoughts, challenge them, and replace with them with more optimistic, hopeful, and realistic thoughts. Optimistic thoughts about ourselves and our ability to achieve our daily tasks and reach our long-term goals can fuel the effort that we need to succeed. Proficiency in the full range of areas of cognitive functioning are critical to achieving goals such as returning to school, completing a degree, getting, and keeping work, living independently, making, and keeping friends, and having deep and rewarding relationships.

The good news is that we can sharpen and extend our mental capabilities and maximize our chances of succeeding in any area we choose.  We can do all of this by using cognitive self-management strategies. Although some may not be familiar with the term “cognitive self-management strategies,” all of us almost certainly use at least some these strategies in our daily lives. Have you ever:

• set an alarm to remember to take a medication, feed the dog, or turn off the oven?
• left yourself a phone message to remember to send a birthday card to your mother?
• tied a string around your finger as a reminder to buy milk?
• put your keys in a special place when you come home so you know where you can find them?

If so, then you’ve used cognitive self-management strategies. And if you have used one of the above, then you’ve probably used some of the other many possible strategies. While everyone uses cognitive self-management strategies, the more we use the better, and everyone can benefit from learning more strategies or how to use them more efficiently.

We describe below self-management strategies for optimizing and extending thinking skills that can be used in all walks of life. Self-management strategies help us utilize our cognitive skills and the demands on them to maximize their efficiency and effectiveness. Additionally, and perhaps surprisingly, practice and expertise in using these strategies, and incorporating them into our daily routines, further enhances our cognitive abilities in areas such as attention, memory, planning, and flexible (and positive) thinking! Thus, in addition to helping compensate for the cognitive limits everyone has in specific cognitive areas and extending our cognitive reach, practiced use of these strategies can also improve our raw brain power.

Learning and using cognitive self-management strategies can help optimize functioning across a range of daily life activities, such as self-care (such as grooming and hygiene, sleep, managing a medical condition), organizing one’s living space, planning for meals, shopping, connecting with friends or family, work or school, and just plain enjoying life (such as getting out to that movie we’ve been thinking of seeing). For example, common problems such as being late or missing appointments, having difficulty keeping focused on a task, or forgetting instructions or someone’s name can all be prevented by using strategies such as maintaining a personal schedule (and using alarms as needed), removing distractions from one’s environment (such as cell phone or computer alerts), and repeating back/paraphrasing what someone has just said, respectively. Some of these strategies focus primarily on one area of cognitive functioning, such as reducing distractions in one’s environment to improve attention and concentration. Other strategies are helpful for improving the broad range of cognitive performance in daily life (e.g., attention, memory, problem solving), such as developing routines at home, when looking for a job, and at school or work. Because obtaining a job (or getting a promotion at work) or completing a degree or certificate program at school are very common goals for people that have a range of cognitive demands, we address some self-management strategies that are particularly helpful for success in these areas.

The table below contains examples of cognitive areas that are important for work and school, signs of a problem related to each cognitive area, and self-management strategies for addressing (or preventing) each problem

The Thinking Skills for Work* program contains a rich curriculum of cognitive self-management strategies which are incorporated into a series of educational handouts for clients. The self management topics include Cognitive Skills for Work, Recognizing Your Strengths, Challenging Negative Thinking, Improving Attention and Concentrations, Reducing Memory Difficulties, Getting Organized at Home, Getting Organized for Your Job Search, Planning Ahead, Solving Problems, and, Improving Thinking Speed. The handouts provide information about strategies for improving cognitive performance at work in attention and concentration, memory, information processing speed, planning, and solving problems. In addition, several other handouts are devoted to enhancing motivation which can contribute to greater effort and persistence at cognitive tasks, including understanding the relationship between cognitive functioning and work (Cognitive Skills for Work)developing an awareness of one’s personal strengths (Recognizing Your Strengths), and overcoming negative thinking or defeatist thinking that can interfere with getting or keeping a job (Challenging Negative Thinking), (e.g., “No one will ever hire me for a job”). Strategies geared toward successful work are also highly applicable to success in school. The Thinking Skills for Work intervention is a comprehensive program for improving and optimizing your cognitive skills. A comprehensive description of the program can be found at here

*SR McGurk, KT Mueser (2021). Cognitive Remediation for Successful Employment and Psychiatric Recovery: The Thinking Skills for Work Program. Guilford Press, New York.

Information about the book can be found here.

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Influencing State Policy Regarding Peer Support with guest expert Noah Abdenour. ASK ME ANYTHING INTERACTIVE WEBINARS WITH AN EXPERT IN EMPLOYMENT

Save the Date: Friday, May 12th 12:00- 1:00 PM EST BOSTON UNIVERSITY You’re invited to ask an expert about another interesting topic related to employment! This free event is not a presentation but rather an interactive question & answer webinar. And YOU provide the questions. Submit webinar questions before the webinar Le MS lynleg@bu.edu’

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by Sally Rogers and Lyn Legere

The role of peer specialists in behavioral health settings has grown dramatically in the last couple of decades. But, as a relatively new addition to the workforce, it is experiencing “growing pains”. Common experiences relayed by peer support workers include a lack of clarity about how their role fits into the mental health workplace and confusion about what their work tasks should and should not be. For some behavioral healthcare workers, research suggests that this results in stress, distress and burnout, all of which have worsened because of the pandemic (Edú-Valsania, Laguía, & Moriano, 2022; Sklar, Ehrhart, & Aarons, 2021).

The Center for Psychiatric Rehabilitation has a long history of collaborating with peer specialists in a variety of ways. In this case, we wanted to support peer workers and were troubled by the usual approaches. We often saw solutions suggesting that the peer worker needed therapeutic intervention or that the job needed to be redesigned to lessen the stress. We found both of these approaches to be objectionable, as they merely reinforced the idea of pathology on the part of the peer worker rather than considering the work setting issues related to integrating a new workforce.

Looking at the situation from a workforce perspective, we decided to address this problem with a somewhat novel approach: that of coaching. We know that coaching is an effective tool and has now been applied not only to the sports context, but to lifestyles, wellness, and recovery (Sforzo, et al., 2018; Grover & Furnham, 2016). Most relevant, it has proliferated in work settings, including Executive Coaching. We wondered if Executive Coaching for peer specialists, which keeps the focus squarely on the workplace, might be an effective approach to address work related stressors.

Coaching shares many values of peer support, which makes it very attractive. Some of the advantages of coaching support is that it focuses on establishing a good working relationship and mutual respect, on co-developing goals, and on bringing self-directed strategies to bear to support the person as they strive to reach their goals.

However, we wanted to differentiate coaching for peer workers from typical “Executive Coaching” in that we did not want to have any affiliation with the person’s employer. Coachees were free to tell their supervisors about the coaching, should they choose. At the same time, we believed that having a firewall between the employer and the coach gave the peer worker a greater sense of safety to fully share their work situation without fear of reprisal.

In 2019, the Center submitted a proposal to develop and research this virtual coaching intervention for peer support workers to the National Institute on Disability and Rehabilitation Research, which was funded.

To develop the coaching program, we consulted experts in both fields: peer support practice and coaching. We got input from a small group of peer specialists/advocates and also from the Harvard Institute on Coaching (to learn more about coaching from this institute, visit: https://www.instituteofcoaching.org/). Since the coaching would be focused on work issues, it was clear to us that the coaches must have experience as a peer support worker as well as coaching skills. Lyn Legere, herself certified as a life coach and a peer specialist, took the lead on the development of the coaching guide, working with Zlatka Russinova, Director of Research at the Center, and the input of consultants.

The peer worker coaching manual consists of several sections providing guidance to coaches. One important section specific to this coaching intervention is “Coaching vs. Peer Support.” The coach’s background in peer support provides knowledge needed to understand challenges that coachees may be experiencing. Here, however, their role is that of a coach. We were very fortunate to have hired two highly experienced peer specialists who were trained to be coaches for this study and who have done an exemplary job.

Another important section of the manual is what we called the Topical Guide. This section focuses on areas that we know can be particularly challenging in peer work, including:

· Role Overload

· Role Confusion/Ambiguity

· Work/Life Imbalance

· Stigma and Role Devaluation in the Workplace

· Dealing with Conflict in the Workplace

· Training Gaps or Job Mismatch

· It is What it Is: Dealing with Issues Beyond your Control

· Wellness Tools for Work

Each section has information on the topic as well as tips, strategies and worksheets that can be used in whatever ways seems useful to the coachee.

Of course, funded research has to see how effective any newly developed intervention is. Using surveys, we are trying to learn if the coaching had an effect for people in areas such as role clarity, role confusion, burnout, job satisfaction, organizational climate, job stressors, and turnover intention. Participants complete the survey measures when they first enroll in coaching, and then at the 4, 6 and 9-months mark.

Since this study was developed as a randomized trial, only half of the people we enrolled will get the full coaching (designed to be up to 16 weeks long) and the other half are offered one informational session. This will allow us to make good comparisons about the effect of the coaching. Because the project is ongoing, we do not have this data compiled yet, but hope to have some initial outcomes by the endo of 2023.

In the meantime, we have also been conducting qualitative interviews with folks who have received coaching. From these interviews, we are learning of the value that participants place on having a knowledgeable peer specialist/coach to discuss their workplace difficulties with, someone who can provide perspective, context, and understanding. Here are some of the things the coachees said:

• “Coaching helped humanize my work”

• “My coach was a lifeline during a difficult time for me personally”

• “I could trust my coach when I hadn’t trusted other providers”

• “Coaching was terrific”

• “It was lifechanging for me…I learned about myself as a peer and it helped me in my life”

• “Personal growth and development—coaching helped me be the best me that I could be and bring that to work’’

• “They listened…”

• “Overall, for me, what feels the most helpful, is knowing that when Sunday at 1 comes, there was somebody who gets it, who gets what it’s like to do this work, who gets what it means to have a mental health condition—that alone has been helpful—knowing this carried me through each week”

For those interested in learning more about the work of peer specialists, please visit the NAPS website: https://www.peersupportworks.org/

The Substance Abuse and Mental Health Services Administration also has information about peer specialists: their role and their competencies. https://www.samhsa.gov/brss-tacs/recovery-support-tools/peers; https://www.samhsa.gov/brss-tacs/recovery-support-tools/peers/core-competencies-peer-workers

If you want additional information about this project, please contact E. Sally Rogers, Project Director at erogers@bu.edu or Lyn Legere, Senior Training Associate at lynleg@bu.edu.

Citations:

Edú-Valsania, S., Laguía, A., & Moriano, J. A. (2022). Burnout: A review of theory and measurement. International journal of environmental research and public health, 19(3), 1780.

Grover, S., & Furnham, A. (2016). Coaching as a developmental intervention in organisations: A systematic review of its effectiveness and the mechanisms underlying it. PloS One, 11(7). doi:10.1371/journal.pone.0159137

Sklar, M., Ehrhart, M. G., & Aarons, G. A. (2021). COVID-related work changes, burnout, and turnover intentions in mental health providers: A moderated mediation analysis. Psychiatric Rehabilitation Journal, 44(3), 219.

Sforzo, G. A., Kaye, M. P., Todorova, I., Harenberg, S., Costello, K., Cobus-Kuo, L., . . . Moore, M. (2018). Compendium of the Health and Wellness Coaching Literature. American Journal of Lifestyle Medicine, 12(6), 436-447. doi:10.1177/1559827617708562

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Ask Me Anything: Supervising the Peer Workforce in Behavioral Health Settings 

You’re invited to ask an expert about another interesting topic related to employment! This free event is not a presentation, but rather an interactive question & answer webinar. And YOU provide the questions.

Save the Date:  Monday, February 13th at 12:00 – 1:00  PM (Eastern)

Ask Me Anything About …

Supervising the Peer Workforce in Behavioral Health Settings with guest expert Amy Pierce

Amy Pierce, MHPS, PSS, ALF 

Amy has been working in the peer movement in the State of Texas for almost two decades and now serves as the Recovery Institute Deputy Director.  Previously, she was the CEO of Resiliency Unleashed, an international training and consulting company focusing on the development and implementation of peer services. She started the first peer support program in the Texas State hospital system, was a peer support worker in a community mental health agency and served as the Program Coordinator for a transitional peer residential housing project funded through the 1115 waiver program. Amy has held supervisory roles within these programs, developing training for providers across Texas and beyond.  Amy is a Mental Health Peer Specialist, a Certified Peer Specialist Supervisor, and trainer/facilitator (Advanced Level Wrap facilitator, ASIST trainer, WHAM facilitator). Amy is a previous chair of the PAIMI council and is a current board member for Disability Rights Texas.

Zoom Registration:  https://bostonu.zoom.us/webinar/register/WN_Tymu99ALReOCUBvV4PFTiA

Submit webinar questions before the webinar to

Lyn Legere, MS at lynleg@bu.edu

Tech Requirements:
The registration and webinar will be conducted through Zoom Conferencing. Once you complete the registration process you will receive an e-mail with the Zoom link for the webinar. If you do not have the Zoom app installed on your computer, tablet, or smartphone, you will be directed through the download process upon registration.

Accommodation Requests: 
Boston University provides reasonable accommodation upon request. Please send an email to lynleg@bu.edu 14 days prior to the event with the specific accommodations you require. If less than 14 days remain until the event, please submit your request the same day you register, or as soon as possible, so we can make every effort to accommodate you.

This event has passed. View the webinar recording in our archives here.

The Online Technical Assistance (OTAR) model  was developed as a pilot program, with the goal of assisting organizations (e.g. state agencies, providers, for- and non-profit entities) that want to improve  their employment outcomes for people with psychiatric disabilities by improving their policies, funding, and system design.

Two elements of this are:

Program providers perform an assessment of the need for “technical assistance” (TA) services around a specific group of an organization’s [employment focused] goals for the clients or patients it serves. Once the needs of the organization are identified, the consultant develops a site-specific TA plan based on the organization’s response to this assessment. OTAR clarifies a focus on policy and systemic change within participant organizations more than it focuses on training or product development. The model also emphasizes the importance of assigning a subject matter expert (SME) for each organization. Often, it has been advantageous to pursue candidates new to the consulting field with an opportunity to be part of this team and take on this role.

The second step is the construction of an implementation team which includes supervisory and clinical management staff as well as relevant partner organization personnel. The OTAR implementation team conducts regular Zoom calls to review the steps included in the plan.

Typically, sites begin their participation through word-of-mouth and email recruitment.

Once interest is expressed, potential sites are requested to answer the following simple questions:

• What would you like to get out of OTAR this year?
• What problems would you like the TA to solve or issues with which the TA might help?
• What would you hope would be concretely different if the TA were successful?
• If someone came back 1 year after the process was complete, what would that person see in terms of the system your organization uses to assist people with psychiatric disabilities become successfully employed?

Since the project commenced in 10/19, OTAR has worked with several organizations across the country. They have included:

• 3 State Behavioral Health systems
• 1 county Behavioral Health system
• 2 State public VR systems
• 2 statewide non-profit employment service providers’offering services to job seekers with psychiatric disabilities
• 1 county based non-profit employment service provider that aids clients with behavioral health disabilities
• 1 large city housing provider that serves thousands of people with various barriers to employment including behavioral health problems, homelessness, poverty
• 1 mental health oriented social service housing and clinical organization in a farm like environment
• 1 small rural housing provider that serves 20 people who have experienced mental illness
• 4 CMHCs that offer an array of behavioral health services including employment
• 1 large behavioral health managed care entity serving a large portion of a state
• 1 large statewide consumer run organization that provides peer supports, community psychiatric rehabilitation, and housing services.

The specific requests for TA varied by site but most incorporated the importance of employment as a core part of Recovery planning in clinical services instead of as a referral point to an employment unit. These included both micro-level discussions on motivating clinical staff to generate interest in employment with their clients and a broader systems-level focus on creating large scale policy and funding models to increase employment outcomes. A few projects related to how to create a system of financial planning advice early in the process for job seekers with disabilities, albeit one short of the more time-consuming full SSA benefits analysis.

So, what have we learned?

• Remote technical assistance can be useful to a variety of settings interested in enhancing the role of employment within Recovery oriented systems of care.
• It is useful to engage potential recipients in a self-assessment to help define the concrete activities that might attend to the needs identified – the more concrete the recipient organization is on stating needs, the easier it is to respond effectively.
• It is often the case that the first needs organizations identify as those impeding employment are not necessarily the same ones that emerge as the TA continues and other issues are examined.

There are also downsides that have emerged from the online technical assistance model. The initial outreach and engagement with OTAR was presented as a joint priority of each partnering agency with the site’s focus on mental health and employment collaboration. In practice, the commitment to the planned efforts often continued only with some of the participating sites. This most commonly emerges in the context of an employment focused organization getting only intermittent support from the mental health organization (state or local) involved. While the agreement obtained from all sites was to involve at least one of the clinical supervisory and/ or executive level staff, some sites have had only intermittent buy-in from personnel at these levels.

Another downside is that site visits are typically used to expand the pool of informants about the local issues supporting or impeding employment. This activity gets lost with distance-TA-only conditions – those in which the consulting team only has direct involvement with the formal coordinating [on-site] group and captures only a limited view of the local environment. Another downside from the consultant perspective is that it is less satisfying and less fun to be unable to connect with local sites in a more personal relationship and to directly observe the impact of the program. It is conceivable that some form of hybrid model could address these issues in the future.

For more information about  OTAR services contact us at psyrehab@bu.edu.

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Brief History 

The Center for Psychiatric Rehabilitation (CPR) at Boston University has partnered with the voices of those with lived experience from its’ earliest days (i.e., the voices of those who would eventually populate the peer support specialist workforce).  Luminaries in the field such as Pat Deegan, Judi Chamberlin and Dan Fisher, were among the many people with lived experience who collaborated with Bill Anthony and colleagues in the formative days of the CPR.  Due to the strong parallel in values of the CPR and the consumer/survivor/ex-patient (c/s/x) movement, it was only natural for each to support the work of the other.

The CPR was an ally in the advocacy work of movement activists.  Those early days focused on “consumer” voice and participation in mental health policy and practice, under the motto, “Nothing About Us Without Us.”  Simultaneously, the power of peer relationships in peoples’ healing and recovery, called “peer support” today,  was highlighted in Judi Chamberlin’s  seminal book, “On Our Own,” and incorporated into the values and practices of psychiatric rehabilitation.

Prior to Medicaid funding, some headway was made with the creation of a “consumer liaison” role in some states, and other nominal “consumer” roles in services.  However, even the willing were hindered by the usual issue, i.e., funding.

The “Certified Peer Support Specialist”

In 1999, the Georgia Mental Health Consumer Network gained Medicaid approval (i.e. funding) for a new role – “Certified Peer Specialist” By 2005, states across the country began to follow Georgia’s lead and when the Center for Medicare and Medicaid Services (CMS) not only endorsed peer support as an emerging best practice in 2007, but encouraged states to utilize peer support,[1] the flood gates opened.  By 2016, there were at least 25,317 peer support specialists in the US.[2]  The rare “consumer” role of the 1990’s has now become a common role throughout behavioral health.[3]  It should be a time to celebrate all that has been accomplished, right?  Well, maybe….and maybe not.

Unintended Consequences

The word “peer” in “Certified Peer Specialist” is intentional and signifies the mutual relationship between two people with shared experience that was the hallmark of peer relationships in the c/s/x movement communities.  The intent of the “Certified Peer Specialist” role was simply to bring this impactful community role into services to create access for people who couldn’t access and get the benefit of peer-run agencies in the community. Peer support is meant to offer the comfort of “been there, done that” and the hope of “…and I’m not there now.” The peerness of the relationship – that is, no one holds power over the other – is what separates peer support from other roles and is often what opens the door to connection and trust.  There are many more professionals working in mental health, sharing their lived experience..  However, with or without lived experience, the traditional workforce still holds power over people in services.  An authentic peer specialist does not.  They are meant to be “in but not of” the system as a new and different type of provider unconnected to the culture of the medical model.

With hindsight, it’s clear that implementation of the role skipped the vital steps of preparing agencies and their staff for the influx of Certified Peer Specialists, resulting in a clash of cultures. (Byrne et al., 2019.  “The emphasis was initially on bringing the values and principles of peer-developed peer support into paid peer staff roles, but the ability to keep the focus on these values [is]often compromised by clinicians and administrators who do not understand or support the principles (Jones et al, 2020; Stastny & Brown, 2013).

Inevitably, the role has become co-opted, with “mutuality”, the first critical component of peer support to be set on a shelf to get dusty and forgotten. Similarly, “relationship,” is often sacrificed as peer support work often prioritizes the “deliverable” task at the expense of the relationship.   Here’s how one peer provider described their role,

“They changed the scope of what peer support really is… Now there’s that movement that kind of makes people, what I like to refer to as mini clinicians. Minus the white coat, they’ve got their clipboard and they’re taking notes, ‘How does that make you feel?’” (Adams, W. 2020)[4]

Changing the Tide

The Center is dedicated to preserving the “peerness” of peer support specialists.  The Recovery Education Center, provides recovery/wellness education classes, many facilitated by people with lived experience who also provide one-to-one support to students in their classes.  Many former students go on to become facilitators and peer support specialists, themselves.

Research projects, in addition to having people with lived experience involved in research project design  have also focused on delivery of authentic peer support in services.  One example is the Vocational Peer Support (VPS) training that was developed and researched at the Center.  Another is a current study developing a way of providing Executive Coaching for peer supporters.

The Center’s Post-Doctoral Fellows have also focused on authentic peer support. The most recent example of this is Wallis Adams who, partnering with the National Association of Peer Supporters (NAPS) performed two studies:  The Impact of Covid on Peer Support Specialists and Barriers and Facilitators of Implementing Peer Support Services for Criminal Justice-Involved Individuals.

Continuing this tradition, the Center will be dedicating a series of webinars ( “Ask Me Anything”) on the peer support specialist workforce in 2023. Announcements will be made when registration is open for these.

The role of people with lived experience, as well as the peer support workforce, will continue to be at the heart of research, training and services at the Center.

[1] CMS Letter dated August 8, 2007 (SMDL #07-011).

[2] Wolf, J. (2018). National trends in peer specialist certification. Psychiatric Services 69 (10), 1049. This number does not include thousands of non-certified peer support workers as well as those employed in forensic, youth, parent partners, substance use and other behavioral, primary and integrated health settings as well as serving specific population groups.

[3] Cronise, R., Teixeira, C., Rogers, E. S., & Harrington, S.(2016) The peer support workforce: Results of a national survey.,  Psychiatric Rehabilitation Journal, 39(3), 211-221.

[4] Adams, W. 2020. Unintended Consequences of Institutionalizing Peer Support Work in Mental Healthcare. Social Science & Medicine, 262.

Welcome to the Center for Psychiatric Rehabilitation official blog! For our inaugural article, we thought we would tackle a basic question that the Center has contributed to answering over the years, i.e. What exactly is “psychiatric rehabilitation”?

The Deinstitutionalization Movement

Let’s begin by reviewing one of the most important factors in the historical context of the development of psychiatric rehabilitation: The deinstitutionalization movement in the United States and abroad.

Deinstitutionalization as a movement was motivated by an understanding that the typical incarceration of people with mental health conditions on locked wards in long-stay hospitals, was not necessary. We learned that it was possible to design effective services, in the least restrictive setting, while helping people to keep their personal dignity and self-determination. Following the release of the anti-psychotic, Thorazine and numerous other psychiatric medications, the in-patient census was reduced from approximately 560,000 people in psychiatric institutions in 1955, to approximately 70,000 by 1994. Even though President Kennedy’s Community Mental Health Centers Act of 1963 achieved a breakthrough in developing community services, more than 90% of people – many who spent virtually their entire lives in institutionalized psychiatric settings – moved into communities by the mid 1990’s, often still without sufficient support services in place.

Marianne Farkas, Director of the Training, Dissemination, and Technical Assistance Division here at the Center, recalls doing a project at an in-patient institution in Maine, helping them to improve their deinstitutionalization efforts.  She encountered residents, such as 58-year-old Betty, who were leery of those efforts. Betty had lived in the institution for more than 25 years and was not eager to leave. It is not terribly difficult to understand such an attitude.  Betty watched other residents separated from their routines, caretakers, and friends as they were simply given a prescription for their medication and ushered out the door. These people were unprepared to choose or pursue valued roles in the community. In many cases, people had been institutionalized for so long that mere identification of a community role – something that requires self-knowledge about one’s values and possible options – was a seemingly monumental task. Marianne’s project focused on the facilitation of services to help Betty and others like her, to live in the community, rather than just get placed there, using psychiatric rehabilitation techniques.

Psychiatric Rehabilitation: A Response to the Deinstitutionalization Movement

As the Center’s founder, Bill Anthony once said “If deinstitutionalization was to give freedom to people with psychiatric disabilities, psychiatric rehabilitation would create the space and structure for a meaningful life within that freedom.”

So, what is psychiatric rehabilitation (PR)? The name can be a misleading.  It does not necessarily imply the involvement of a psychiatrist or really of any form of psychiatry. Rather, the term ‘psychiatric’ describes the disability that rehabilitation activities address, just as the term “physical’ rehabilitation describes the kind of condition (i.e., physical disabilities) addressed.  The term ‘rehabilitation’ indicates that the activities are concerned with the performance of a specific role (e.g., worker, student, parent) in specific environments.

PR helps people consider, research, choose and achieve a major role in a specific environment, that is personally meaningful.  These “role goals” may involve, for example, working part-time as cashier at McDonald’s or completing a Community College certificate in Addictions Counseling. The Center’s materials can help providers learn how to use PR techniques to facilitate a person identifying such goals ( e.g., rehabilitation readiness, setting an overall rehabilitation goal).

Psychiatric Rehabilitation vs. Physical Rehabilitation

Different “role goals” make unique demands on an individual in order to succeed, regardless of the source of their challenges. Rehabilitation, of any kind, aims to restore functioning in people’s lives by teaching skills and modifying the environment in order to maximize independence. For example, being able to transfer from bed-to-chair might be a skill necessary for an individual with a spinal cord injury. Railings or other supports might, together with this skill, help that person to perform the tasks needed to succeed in their role as parent at home. In a work role, skills such as accepting negative feedback from a supervisor or improving job-specific skills might be critical for the individual. However, beyond skills, that same individual might need their workspace to conform to wheelchair accessibility guidelines, to support their ability to succeed at work. This combination of skill and environmental support allows the individual, regardless of their type of disability, to perform well in their preferred valued roles.

Psychiatric Rehabilitation Techniques Developed at the Center

Techniques developed at the Center transfer these ideas from the realm of physical rehabilitation to psychiatric services (e.g.. PR Functional Assessment and Skill Teaching) and help people in mental health recovery figure out and develop the skills they need  for their specific selected role goal. Young adults who live with mental health and/or substance use conditions who’ve experienced an interruption to their pursuit of higher education, develop critical skills and supports in the NITEO program, one of many College Mental Health Education Programs at the Center. NITEO supports young adults prepare for a successful re-entry to college. Beyond college, people who want to consider or succeed in work may struggle specifically with cognitive difficulties. Participating in Thinking Skills for Work, developed by the Center’s faculty (Susan McGurk and  Kim Mueser), has been demonstrated to improve employment outcomes when TSW is delivered together with Supported Employment. Thinking Skills for Work (TSW) trains people in core cognitive skills important to the work goal they may have (e.g., paying attention, planning, organizing etc.), as well as self-management skills. For example, one TSW self-management strategy is the use of a “memory spot”, a place selected to regularly keep important personal items like keys or a wallet, to address problems associated with memory problems that interfere with work functioning.

The Importance of the Environment

PR is about the person in the environment. I can be very good at my job and not doing terrifically as a parent. Beyond my parenting skills, I might need environmental modifications and supports. I may need a babysitter to cover time between the end of the school day and when I get home from work. No matter how skilled I am, that support is critical to my success.   Most of us are dependent on some support to succeed in the many roles we juggle in our lives. For example, common supports like public transportation, an alarm set to wake up, having a doctor, friends or recreational facilities can help the average person to succeed, including a person in mental health recovery. The Center’s focus on the importance of such support and strategies to modify the environment-rather than only focusing on changing the person, was a breakthrough in the realm of psychiatric services.  New Center interventions such as Bridging Community Gaps, using Photovoice, help people make better use of what the community has to offer.  Interventions such as PR case management help people to develop and link with needed supports.

The belief that every human being has the right to live a personally defined, meaningful life is a cornerstone of Psychiatric Rehabilitation. Its processes are based on a belief in our common humanity, regardless of the challenges we must face. PR recognizes the importance of supporting people with psychiatric disabilities in identifying and thriving in their preferred valued role.  Consistent with the broader field of rehabilitation science, PR accomplishes its aims with a combination of skill development and environmental accommodation and may encompass a wide range of modalities, depending on the specific roles selected by the person. To learn more about the PR process and approach, check out our Primer on the Psychiatric Rehabilitation Process or, for a deeper dive, consider our textbook: Psychiatric Rehabilitation, Second Edition.

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