psychiatric rehabilitation: past myths and current realities

Communi ty Mental Health Journal , Vol. 22, No. 4, Winter 1986

Psychiatric Rehabilitation: Past Myths and Current Realities

William A. Anthony William A. Kennard William F. O'Brien

Rick Forbess

ABSTRACT: Psychiatric rehabilitation treatment has a unique and complementary contribution to make to the treatment of persons with a severe psychiatric disability. However, the development of the psychiatric rehabilitation field, and the adoption of its philosophy and techniques by mental health agencies, has been hampered by past myths. Research carried out in the 1960s and 1970s has exposed these myths as a part of the past, no longer relevant to the present practice of rehabilitating persons with severe psychiatric disabilities.

In 1977 Anthony characterized the mental health field's capacity to rehabilitate persons with severe psychiatric disabilities in the following way: "In terms of rehabilitation, the mental health system is plagued by poor outcome figures, saddled with inefficient treatment approaches and distracted by an irrelevant diagnostic system" (Anthony, 1977, p. 658). The research supporting this charac- terization has been summarized repeatedly, most recently by Anthony and Nemec (1984). The admitted failure of existing treatment techniques to successfully rehabilitate persons with severe psychiatric disabilities has stimulated the growth of the psychiatric rehabilitation field.

PSYCHIATRIC REH ABILITATION FIELD

The psychiatric rehabilitation field has progressed to the stage where its mission and philosophy can be articulated, the characteristics of its intended recipients described, its outcomes specified and measured, and its major interventions described and monitored.

In essence, the overall mission of psychiatric rehabilitation is to ensure that the person with the psychiatric disability can perform those physical, emotional, and intellectual skills needed to live, learn, and work in his or her own particu-

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lar community, given the least amount of intervention necessary from agents of the helping professions (Anthony, 1979).

The target population of psychiatric rehabilitation are those persons who have become disabled due to psychiatric illness. There are several definitions of severe psychiatric disability which characterize this target population, including the definition currently used by the National Institute of Mental Health's Com- munity Support Program (CSP) (Stroul, 1984), the Rehabilitation Services Ad- ministration's (RSA) definition of severe disability (Skelley, 1980), and Gold- man's (Goldman, Gattozzi and Taube, 1981) definition of the "chronically mentally ill." Each of these definitions (CSP, Goldman, RSA) shares common elements, i.e., a diagnosis of mental illness, of prolonged duration, with result- ing functional or role incapacity. It has been estimated that there are between 1.7 to 2.4 million severely psychiatrically disabled persons in the United States (Goldman et. al, 1981).

The outcome of a psychiatric rehabilitation intervention for severely psychiatrically disabled persons are measures of: 1) client behavioral change, or 2) client and society benefits (Anthony, 1984; Anthony and Farkas, 1982). Measures of client behavioral change provide an indicator as to whether the clients are able to do anything differently as a result of their involvement in a psychiatric rehabilitation intervention, that is, what skills (e.g., conversing with parents) or activities (e.g., joining a club) are they now performing, either in the rehabilitation setting (e.g., completing work tasks on time at the sheltered work- shop) or in a non-rehabilitation environment (e.g., conversing with parents at the dinner table). Measures of client and society benefits provide an indicator as to what the client and/or society receives because of the psychiatric rehabilitation intervention. Simple measures of recidivism and days spent in the hospital or community have been used as rough estimates of client and society benefits. Other types of benefit measures are estimates of the clients' satisfaction with their life situation and measures of living, learning and working status, e.g., level of employment, degree of independent living, educational achievement.

A psychiatric rehabilitation intervention focuses on: 1) changing the clients skills, or 2) changing the clients environmental supports, or both. The assumption of psychiatric rehabilitation is that by changing the person's skills and/or environmental supports benefits will accrue to the client and society.

DISPELLING THE M Y T H S OF THE PAST

In order for the field of psychiatric rehabilitation to develop further, and to facilitate the adoption of its philosophy and techniques by mental health settings, a number of myths have to be put to rest. Not only have these myths retarded the field of psychiatric rehabilitation, they have also burdened the field of mental health in general. Research in the 1960s and 1970s exposed these beliefs to be, in fact, myths. The following fifteen myths must become a part of the past so as to no longer hinder future developments in psychiatric rehabilitation.

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TABLE 1 Fifteen Historical Myths

1. Increasing drug treatment compliance can singularly effect rehabilitation outcome. 2. The majority of psychiatrically disabled persons are being successfully rehabilitated. 3. Traditional types of inpatient treatment, such as psychotherapy, group therapy, and drug

therapy, positively effect rehabilitation outcome. 4. Total push inpatient therapies, such as milieu therapy, token economics and attitude ther-

apy, positively effect rehabilitation outcome. 5. Hospital based work therapy positively effects employment outcome. 6. Time limited community based treatment is superior to hospital based treatment in terms

of rehabilitation outcomes. 7. Community based treatment settings are well utilized by persons who are psychiatrically

disabled. 8. Where a person is treated is more important than how a person is treated. 9. Psychiatric symptomatology is highly correlated with future rehabilitation outcome.

10. A person's diagnostic label provides significant information relevant to a person's future rehabilitation outcome.

11. There is a strong correlation between a person's symptomatology and a person's skills. 12. A person's ability to function in one particular environment (e.g., a community setting)

is predictive of a person's ability to function in a different type of environment (e.g., a work setting).

13. Rehabilitation outcome can be accurately predicted by professionals. 14. A person's rehabilitation outcome is a function of the credentials of the mental health

professional with whom the person interacts. 15. There is a positive relationship between rehabilitation outcome and the cost of the inter-

vention.

Fifteen Myths of the Past

Myth Number One: Increasing drug treatment compliance can singularly effect rehabilitation outcome. T h e a d v e n t o f d r u g t h e r a p y t h r e e d e c a d e s ago was t h o u g h t b y s o m e

to e l i m i n a t e the n e e d for r e h a b i l i t a t i o n . T h e u n b r i d l e d e n t h u s i a s m s u r r o u n d -

i n g the d e v e l o p m e n t o f d r u g t h e r a p y l ed m a n y b e l i e v e r s to t h i n k t h a t the u l t i -

m a t e a n s w e r h a d c o m e :

(These new drugs) were hai led as the solution to the problems of near ly all mental i l lness - - they were the panacea , and to the more enthusiast ic, they were the means by which most if not all previous forms of t rea tment could be e l iminated and menta l illness could be eradicated. The popula r press was filled with dra- mat ic examples of work done with the drugs (Felix, 1967, p. 86).

N o w it is r e a l i z e d t ha t the goa ls a c h i e v e d b y d r u g t r e a t m e n t , wh i l e still d r a -

m a t i c , a r e s o m e w h a t m o r e m o d e s t . S o m e o f the goa ls a c h i e v e d b y d r u g t h e r a p y

a r e a r e d u c t i o n o f c e r t a i n p s y c h i a t r i c s y m p t o m s , a r e d u c t i o n in the use o f p h y s -

ical r e s t r a i n t s , an i n c r e a s e in the t i m e s p e n t b y c l i en t s in v a r i o u s f o r m s o f t he r -

a p e u t i c ac t iv i t i e s , a n d a n i n c r e a s e in p s y c h i a t r i c h o s p i t a l d i s c h a r g e s ( A n t h o n y ,

1979). T h r e e d e c a d e s a f t e r the d i s c o v e r y o f the f irst a n t i - p s y c h o t i c d r u g , t h e r e

is l i t t le e v i d e n c e t h a t d r u g t h e r a p y i n c r e a s e s a c l ien t ' s s t r e n g t h s a n d a s s e t s - n o r

s h o u l d it be e x p e c t e d to do so. C h e m o t h e r a p y a l o n e c a n n o t i m p r o v e a p e r s o n ' s


ability to interview for a job, converse with friends, respond to another person's feelings, or program a computer (Engchardt and Rosen, 1976). Furthermore, a series of studies conducted in the United States, Great Britain and France has shown that increased drug treatment compliance does not significantly reduce a person's risk of relapse (Schooler and Severe, 1984).

Drug treatment and rehabilitation treatment are still viewed as complementary treatment approaches. However, the idea of increased drug treatment compliance eliminating the need for psychiatric rehabilitation has become a myth.

Myth Number Two: The majority of psychiatricaUy disabled persons are being successfully rehabilitated. This myth is closely related to myth number one. If drug treatment was as effective as some would have had us believe, then persons being discharged from the hospital were in fact rehabilitated. Unfortunately that was not the reality. A good deal of empirical evidence now exists which exposes this myth. In fact, the majority of persons who leave the hospital return for additional treatment, often repeatedly. Furthermore, only a small percentage of persons discharged from the hospital work in competitive employment.

A large number of studies provide estimates of the recidivism base rate for hospitalized psychiatric patients who receive the traditional hospital regimen of drug therapy and individual or group therapy. Though the studies differ in dates, samples, geographic location, and type of institution, their results are remarkably similar; they suggest a recidivism rate for a one year period of 35 to 50 percent. Estimates of recidivism at three to five years reach 65 to 75 percent (reviewed by Anthony, Buell, Sharratt, and Althoff, 1972; Anthony, Co- hen, and Vitalo, 1978). Reviews of the employment literature over the last ten years have provided similarly discouraging data with respect to the employment outcome of formerly hospitalized psychiatric patients (Anthony et al., 1972; An- thony, Cohen, and Vitalo, 1978; Anthony and Nemec, 1984). The earlier reviews of unemployment data suggested that during the year following discharge, approximately 20 to 30 percent of ex-patients either worked full-time throughout the year or were employed at the one year follow-up date. The later studies which focused on just severely disabled psychiatric patients suggest employment rates of less than 15% with some of the most recent follow-up studies reporting a zero percent employment rate for long-term patients targeted for deinstitutionalization.

Variations of these two outcome criteria-- recidivism and employment-- have been used almost exclusively in early psychiatric rehabilitation outcome studies and have clear advantages. They are objective, have meaning to lay persons, translate readily to economic benefits, and make it possible to compare studies using similar outcome measures. In spite of the advantages, though, a broader range of outcome measures has been recommended for use in future studies (Anthony et al., 1972; Anthony, Cohen and Vitalo, 1978; Anthony and Farkas, 1982; Bachrach, 1976; Erickson, 1975; Mosher and Keith, 1979). A recent review of rehabilitation research indicates that this more refined approach to outcome measurement is in fact occurring (Anthony and Dion, 1985).

Myth Number Three: Traditional types of inpatient treatment, such as psychotherapy, group therapy, and drug therapy, positively effect rehabilitation outcome. This myth can


be seen as related to myth numbers one and two. It was incorrectly believed that patients were being rehabilitated, and that drug therapy as well as other traditional therapies, were in fact doing the job. Yet now we know that these traditional inpatient treatment methods do not differentially affect rehabilitation outcome (first reviewed by Anthony et al., 1972). These methods were origi- nally designed solely to reduce symptoms or provide therapeutic insight, and little evidence exists suggesting they can do more than this.

Although some new treatment techniques have shown dramatic improvements in patients' in-hospital behavior, they have not yet demonstrated a similar effect on community functioning. In-hospital behavior does not correlate with community behavior (Erickson, 1975; Erickson and Hyerstay, 1980). The behavior of the psychiatrically disabled is determined, to a large extent, by the situation in which the behavior occurs; and the behaviors demanded by the hospital environment do not necessarily resemble those needed to function in the community.

However, several innovative inpatient programs, all extremely comprehensive in nature, have demonstrated an effect on community functioning (Becker and Bayer, 1975; Carkhuff, 1974; Heap et al., 1970; Jaeobs & Trick, 1974; Paul and Lentz, 1977; Waldeck et al., 1979). These approaches are characterized by a primary focus on developing patient skills training programs, within an atmosphere in which the treatment staff believe themselves to be an important component of the treatment program, and which include outreach into the community.

Myth Number Four." Total push inpatient therapies, such as milieu therapy, token economies and attitude therapy, positively effect rehabilitation outcome. It was thought that if traditional inpatient therapies did not make a difference, perhaps an innovative treatment might.

Total push therapy procedures attempt to structure the total hospital environment so that most all of the patients' waking hours are directed at therapeutic ends. Although these procedures (variously described as milieu therapy, attitude therapy, social learning therapy, and token economies) differ in terms of their theoretical base, the techniques used to facilitate change, and the systema- ticity of their application, they agree on the necessity of therapeutically struc- turing the patients' total hospital environment.

In terms of rehabilitation, these programs are similar in an even more basic way. While all these approaches have been able to demonstrate positive effects on in-hospital behavior, they have not as yet demonstrated their effects on measures of community adjustment. The outcome studies that have been done have typically confined their analysis to changes in the patients' ward behavior (e. g., Foreyt and Felton, 1970).

These innovative treatments were introduced with great promise. To their credit the proponents of these treatments research their effectiveness on out-of- the-hospital funtioning. It is now a myth that any one of these treatments, conducted only on an in-patient basis, can singularly effect rehabilitation outcome.

Myth Number Five." Hospital based work therapy positively effects employment outcome. Over a decade ago Kunco (1970) surveyed the literature on work therapy and concluded that the research does not support the idea that inpatient work ther-


apy can be therapeutic. He estimated that regardless of whether patients receive work therapy, 33 percent will become employed, a finding consistent with the base-rate data presented earlier. One study (Walker, Winick, Frost and Lie- berman, 1969), which contrasted two types of work therapy, reported that at a six-month follow-up 36 percent of both groups "held regular competitive work at some time during the six months."

Some researchers (Barbee, Berry, and Mikel, 1969) have suggested that work therapy may foster institutional dependency. Their results indicated that patients participating in work therapy remained longer in the hospital than non- participants. During the two year follow-up, 46 percent of the work therapy group and 23 percent of the non-participants were readmitted to the same hospital. However, when readmission to all psychiatric facilities was examined, there were no significant differences between groups. More recent reviews of vocational rehabilitation research with more severely psychiatrically disabled persons, while finding lower employment percentages, report no studies attesting to the efficiency of hospital based work therapy at impacting employment outcome (Anthony, Cohen and Vitalo, 1978; Anthony, Howell and Danley, 1984).

Myth Number Six: Time limited community based treatment is superior to hospital based treatment in terms of rehabilitation outcome. This is a tough myth with which to be confronted. While it has become easy to admit that hospital programs aren't working, the myth has been that most anything attempted in the hospital can be done better in the community. In general, however, this has not been the case.

The body of literature concerning the relative effectiveness of institutional versus alternative placement for the psychiatrically disabled is both sparse and somewhat contradictory. Test and Stein (1978) reviewed a series of studies (David, Dinitz and Pasamanick, 1974; Herz, Spitzer, Gibbon, Greerspan and Reibel, 1974; Langsley, Machotka and Flomenhaft, 1971; Langsley and Kaplan, 1968; Michaux, Chelst, Foster and Pruin, 1972; Mosher and Menn, 1978; Pasamanick, Scarpitti and Dinitz, 1967; Polak, 1978; Rittenhouse, 1970; Stein and Test, 1978; Test and Stein, 1977, Wilder, Levin and Zwerling, 1966) that compared various community alternatives to in-hospital treatment on the following outcome variables: time out of the hospital and readmission rates; psychiatric symptomatology; psychosocial functioning, e.g., role performance; employment and social functioning; and client satisfaction. After discussing the methodological caveats concerning comparability of design and quality of outcome measures, and noting the diversity of treatment modalities, duration of treatment, and methods for outcome measurement, Test and Stein (1978) ob- served that there was concordance in the results for certain outcome measures. They concluded that community treatment initially results in less time spent in the hospital, but after one year the difference disappears; that there is no difference in the amount of symptom reduction between community alternative and in-hospital treatment; and that there is no difference between the in- hospital and community treatment groups in the amount of change in psychosocial functioning.

Dellario and Anthony (1981) reviewed additional studies not referenced by Test and Stein (1979) and arrived at similar conclusions. They concluded that

Will iam A. Anthony, et al 255

once treatment is withdrawn, there is no significant difference between the two treatment settings on symptom reduction, psychosocial functioning, instrumental functioning and personal adjustment. Initial differences that have been reported regarding rehospitalization, time spent in hospital, and employment, tend to wash out by eighteen months following treatment termination. While there are some exceptions, (for example, the Weinman et al., 1974, study indicated significant differences in rehospitalization at 24 months), the weight of evidence seems to support the conclusion that, regardless of the type of community based alternative, there is no long lasting superiority of time-limited, community based alternative treatment compared to time-limited, in-hospital treatment. It also seems evident that, without interventions designed to directly effect sustained long term outcome, sustained long term progress on any outcome indicated should not be expected, regardless of the institutional or community location of the treatment setting.

Interestingly, both reviews (Dellario and Anthony, 1981; Test and Stein, 1978) did report significant differences in patient satisfaction, favoring the community settings. Consumers remind us that this is an important outcome variable. However, it is easy to speculate that these differences in satisfaction may not reflect program differences, but rather, the fact that community programs offer the client relatively more freedom.

The most cited review of comparative studies of institutional versus community based treatment was authored by Kiesler (1982). He reviewed ten studies in which severely psychiatrically disabled persons were randomly assigned to either inpatient care or some alternative mode of outpatient care. Kiesler (1982) concluded that in no case were the outcomes of hospitalization more positive than alternative community treatment. However, in contrast to the other two reviews, Kiesler (1982) did not report the community program's effect once the program ended, i.e., time limited community treatment. The implication of the need for long term as opposed to time limited community care is obvious.

Myth Number Seven." Community based treatment settings are well utilized by persons who are psychiatrically disabled. While it may be that persons who use the community services are more satisfied with them than hospital services, the overall utilization figures do not attest to their popularity. At issue is the inability of the mental health system to convince many psychiatrically disabled clients to both accept and remain in community based treatment. Wolkon (1970) has reported one study in which approximately two thirds of patients referred to an outpatient setting failed to appear for treatment. Equally discouraging are the statistics provided by Sue, McKinney, and Allen (1976). These researchers reported that of the 13,450 clients seen in the nineteen mental health facilities, 40 percent terminated treatment after one session. Community clinics must determine not only the type of patient who can most benefit from their services, but also how to ensure that this type of patient actually does appear and continue in treatment.

Because of the inadequate utilization of after-care clinics, the introduction of such services may not always produce the expected reduction in community wide outcome figures. McNees et al. (1977) attempted to determine how recidi-


vism has been affected by the development of after-care programs in three Ten- nessee counties. Although countywide statistics revealed no clear reduction in recidivism rates, recidivism rates were substantially lower for individuals who contacted the after-care program than for those who did not contact the program.

Myth Number Eight: Where a person is treated is more important than how a person is treated. The identification of this statement as mythical flows naturally from the preceding myths. To even ask about the relative effectiveness of institutions versus community based alternatives implies that the where of service delivery is a primary factor in determining the effectiveness of psychiatric rehabilitation. However, the body of evidence clearly demonstrates that following the termination of treatment, there is little appreciable difference between subjects treated in institutions and those treated in community based alternatives. This finding raises the possibility that the where of service delivery is less important than the what and how of service delivery.

The question of relative effectiveness of institutional and community based alternatives can be asked at two levels: their effectiveness relative to each other, and their effectiveness relative to their potential functions. The second question may be the more sensible one; hospital and community based approaches should be viewed neither as mutually exclusive nor as necessarily antagonistic, but rather as complementary sources of potential impact on a variety of criteria pertaining to psychiatric rehabilitation outcomes.

For example, Waldeck, Emerson and Edelstein (1979) described a program designed to help psychiatrically disabled individuals make the transition from institutional living to community living. It emphasized in-hospital training and systematic after-care as two points on a continuum of treatment. The community orientation and evaluation program (COPE) consisted of a sequenced process of in-hospital skill training and community integration whereby independent functioning in the community is predicated on successive and cumula- tive skill proficiencies that are necessary for the client to meet basic needs. The initial outcome data from this project indicated that, during the first nine months of operation, the program had an 86 percent rate of non-return. This program views in-hospital and community based treatment modalities as complementary service delivery systems, rather than as mutually exclusive alternatives.

Myth Number Nine: Psychiatric symptomatology is highly correlated with future rehabilitation outcome. A number of studies have now been done which illustrate the lack of relationship between a variety of assessments of psychiatric symptomatology and future ability to live and work independently (Ellsworth et al., 1968; Green et al., 1968; Gurel and Lorei, 1972; Moller et al., 1982; Schwartz et al., 1975; Strauss and Carpenter, 1972, 1974; Wilson et al., 1969).

In particular, there appear to be no symptoms or symptom patterns which are routinely related to individual work performance. On occasion, the studies have generated data contrary to what might be expected. For example, Wilson et al. (1969) found future vocational performance to be related to higher levels of aggressiveness and depression. An analysis of these studies indicates that vocational performance does not correlate with: tension, distress/alienation, anti-


social behavior (Lorei, 1967); depression, anxiety, paranoid hostility, deterio- rated thought (Ellsworth et al., 1968); alertness, orientation, use of defenses (Green et al., 1968); anxiety, verbal hostility, depression (Gurel and Lorei, 1972); thought disorder, depression, flattened emotion (Strauss and Carpenter, 1974); confusion, mania, depression (Schwartz et al., 1975); and global psychopatho- logical state (Moller et al., 1982).

Myth Number Ten: A person's diagnostic label provides significant information relevant to a person's future rehabilitation outcome. This myth flows directly from Myth Number Nine.

Based on previous findings of no consistent relationship between psychiatric symptoms and rehabilitation outcome, it would be expected that there would be no relationship between diagnosis and future independent living and vocational functioning~ An overwhelming number of studies have confirmed the ab- sence of such a relationship (Distefano and Pryer, 1970; Douzinas and Car- penter, 1981; Ethridge, 1968; Freeman and Simmons, 1963; Goss and Pate, 1967; Hall et al., 1966; Lorei, 1967; Moller, 1982; Sturm and Lipton, 1966; Watts and Bennett, 1977; Wessler and Iven, 1970).

With respect to the concerns of psychiatric rehabilitation, the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III, 1980) is a small improvement over its predecessors. The inclusion of a global assessment scale (Highest Level of Adaptive Functioning Past Year, Axis V) and of a global assessment of the client's environment (Severity of Psychosocial Stressors, Axis IV) is to be commended, but their inclusion as optional categories "for use in special clinical and research settings" is unfortunate. No information on client skills is included, nor is any method of specifying the environment in which the client needs or wants to function. As described in the Manual's introduction, this edition attempts to be more descriptive and can be used in the initial steps of treatment planning; however, it focuses on collecting information that has limited predictive value for psychiatric rehabilitation practitioners. As a useful document in the area of rehabilitating the psychiatrically disabled, the DSM-III leaves much to be desired.

The data which attests to the lack of relationship between the diagnostic label and rehabilitation outcome is voluminous. Also problematic is the value of psychiatric labeling, as presently defined and practiced, to do what it was intended to do. The critical problems most often revolve around whether the psychiatric diagnostic system is reliable and valid, or whether the label may do more harm to the person that it might benefit him or her. However, independent of the controversy surrounding the whole issue of psychiatric labeling, there are other reasons why the psychiatric diagnostic system has so little to offer the rehabilitation approach. As the research reviewed suggests, the psychiatric diagnosis does not provide any uniquely relevant information about the person's rehabilitation potential. This finding is really not that surprising as the psychiatric diagnostic system was developed to categorize symptom patterns, not to provide information about a psychiatrically disabled persons' rehabilitation prospects. Independent of the debate over whether the psychiatric diagnostic system does what it was developed to do, it can be said with considerable research support,


that the psychiatric classification system is unable to provide information about the person's rehabilitation potential.

These results do not mean, however, that rehabilitation practitioners cannot use the information collected by traditional psychiatric diagnosticians in their attempts to diagnose the psychiatrically disabled person. Rehabilitation practitioners must educate the traditional diagnosticians as to the information relevant to rehabilitation outcome. Specifically, rehabilitation practitioners should ask the traditional diagnostician for any information which they might have un- covered with respect to the person's skills, skill deficits, interests, and interac- tions with significant others. Some of this information might well be collected during a psychiatric diagnostic interview. The rehabilitation practitioner must be assertive in asking for this information and not settle merely for information about symptoms and labels (Anthony, 1979).

Myth Number Eleven: There is a correlation between a person's symptomatology and a person's skills. A major emphasis in rehabilitation practice is the assessment and development of a person's skills. This is a completely different procedure than diagnosing and treating a person's symptoms. As this myth implies, the two (symptoms and skills) are quite unrelated.

Measures of a psychiatrically disabled person's skills and measures of a psychiatrically disabled person's symptoms show little relationship to one another. This is more apparent in studies which have targeted either skills or symptoms as their treatment focus, but which have still taken measures of both. For example, it is well known that hospitalization and drug treatment affect symptomatology, yet have little impact on a person's vocational skills (Anthony, Cohen and Vitalo, 1978; Ellsworth et al., 1968; Englehardt and Rosen, 1976). In particular the research of Ellsworth et al. (1968) has shown that hospital treatment results in significant symptom reduction but not instrumental performance changes. Examining this issue from a different perspective, Arthur et al. (1968) found symptomatology, and not instrumental behavior, to be related to hospital readmission. Englehardt and Rosen (1976) concluded from their review of drug treatment that while chemotherapy impacts on symptomatology, "evidence for a direct effect of pharmacotherapy on the work performance of schizophrenic patients is so far lacking" (p. 459).

This myth that assessments of symptoms and assessments of function are es- sentially redundant is incorrect, i.e., knowledge of a person's psychopathology does not provide much evidence of a person's functional capacity. A rehabilitation diagnosis with its focus on skills and supports relevant to the persons' goals, must precede a rehabilitation in tervent ion- jus t as a psychiatric diagnosis pre- cedes psychiatric treatment.

Myth Number Twelve: A person's ability to function in one particular environment (e.g., a community setting) is predictive of a person's ability to function in a different type of environment (e.g., a work setting). Various estimates of individuals functioning in their community environment have been used by researchers. These include global ratings of social adjustment, ratings of community adjustment and measures of recidivism. On the basis of several decades of study, the conclusion of researchers is that functioning in one area shows little or no relationship to


functioning in other areas. It is now standard practice in outcome research to assume little or no relationship between measures taken in two different areas of functioning (Anthony and Farkas, 1982; Schwartz et al., 1975). The large scale research of Ellsworth et al. (1968) showed that the situation itself is a power- ful determinant of a psychiatrically disabled person's ability to function. Their research found no relationship between hospital based ratings of adjustment and community based ratings of adjustment (Ellsworth et al., 1968). Forsyth and Fairweather (1961) had previously reported similar findings with respect to the independence of hospital and community adjustment measures.

Concerning employment outcome, a number of researchers have reported only a slight relationship (Forsyth and Fairweather, 1961; Freeman and Sim- mons, 1963; Gregory and Downie, 1968; Lorei and Gurel, 1973) or no relationship (Arthur, Ellsworth and Kroeker, 1968; Wessler and Iven, 1978) between recidivism and post-hospital employment. The lack of a strong relationship between recidivism and employment is somewhat surprising in that those individuals who are working throughout the follow-up period can, by definition, not be recidivists. There appears, however, to be a significant percentage of persons who find work and still recidivate, as well as a group who aren't able to work but still do not become recidivists.

Other researchers have noted the independence between measures of vocational functioning and other types of assessments. Summers (1981) found that while after-care clients showed significant improvement in symptomatology and social functioning over a one year period, their vocational functioning did not similarly improve. In Tessler and Manderscheid's (1982) study of over 1400 severely psychiatrically disabled clients, very low correlations between renumer- ative employment and social activity (.11) and basic living skills (.16) were reported. They concluded that the "results supported the view that community adjustment involves relatively distinct yet independent dimensions" (Tessler and Manderscheid, 1982, p. 206). In several studies of state vocational rehabilitation clients, (a portion of which were psychiatrically disabled) the independence of the vocational dimension from other measures of adjustment was once again confirmed. The results of Bolton (1974), replicated by Bolton (1978) and Gro- wick (1979), showed that measures of vocational success are unrelated to self- reported changes in psychological adjustment.

Strauss et al. (1972, 1974) examined predictors of outcome and focused specifically on four dimensions of outcome: work, symptoms, social relationships, and need for hospitalization. These investigators concluded that each of these areas must be considered separately in the evaluation of the psychiatrically disabled person's functioning. Examining work specificity from still another perspective, several studies (Lorei and Gurel, 1973; Walker aqnd McCourt , 1965) have found no correlation between work activity in the hospital and subsequent community employment. Walker and McCourt (1965) reported that only 26 percent of the patients active in hospital based work activity were employed after discharge; furthermore, twenty percent of the patients who did not partici- pate in work activity in the hospital were also employed after discharge.

In summary, it should be clear from the research that it is a myth to assume


knowledge of a person's vocational capacity based on that person's daily nonvocational functioning, and vice versa.

Myth Number Thirteen: Rehabilitation outcome can be accurately predicted by professionals. Although professionals may fill out rating forms which correlate with post-

hospital employment, there is really no evidence to suggest that they know how to use these ratings to make an accurate prediction (Miles, 1967). If one's only interest was increased predictive accuracy, long-term (3-5 years) prediction could be improved by simply predicting that every psychiatrically disabled person will become a recidivist or unemployed; based upon the base rate figures presented in Myth Number Two, these predictions would be correct approximately 75 percent of the time or more. Obviously, the psychiatric rehabilitation practitioner's diagnostic system must become more refined than predicting failure for everyone! A tentative direction for the refinement of predictive skills would be a sharper focus on indices of the psychiatrically disabled person's present skilled behavior and the level of skilled behavior expected of the person, either by significant others or by the person him or herself (Anthony, 1979).

This myth must make consumers wary when they hear professionals discussing a person's chance for rehabilitation. Are they assuming they can predict behavior across situations (Myth Number Twelve), or are they assuming knowledge of function from knowledge of symptom (Myth Number Eleven)? In either instance, they are dealing in fantasies rather than facts.

Myth Number Fourteen: A person's rehabilitation outcome is a function of the credentials of the mental health professional with whom the person interacts. Professionals from a wide variety of disciplines (e. g., nursing, psychiatry, social work, occupational therapy, rehabilitation counseling, psychology, recreation therapy) are involved in the practice of psychiatric rehabilitation. The clients' rehabilitation outcome is not a function of these credentials (Anthony and Carkhuff, 1976). Nurses do no better than social workers, who do no better than psychologists, etc. While certain programs, for legal reasons, must have certain professionals (most often revolving around medication dispensing and psychological testing), it makes no empirical sense to designate slots in programs by credentials (i.e., so many OT's, Ph.D. psychologists, rehabilitation counselors). Personnel must be assigned to programs based on the skills required to achieve the outcome. One cannot assume a relationship between skills and credentials. Just as a diagnostic label tells us little about a client's skills, a professional label (i.e., R.N., Ph.D., M.D.) tells us little about a practitioners relevant skills.

Whatever it takes to help severely psychiatrically disabled persons is not the exclusive province of any one professional g r o u p - n o r for that matter the exclusive province of professionals. The term "functional professionals" has been coined by C arkhuff (1971) to identify those individuals who heretofore have been called non-professionals, paraprofessionals, companions, volunteers, lay professionals, and sub-professionals. Groups of individuals who have been referred to by these labels include college students, psychiatric aides, community workers, consumers, parents, and mental health technicians. Underlying these different terms is the commonality of functions which binds these various groups and labels together into a single entity. Thus, the "functional professional" in the


mental health field may be defined as a person who, lacking formal credentials, performs those functions usually reserved for credentialed mental health professionals. In psychiatric rehabilitation these functions include skills teaching, re- source coordination and personal support.

Myth Number Fifteen." There is a positive relationship between rehabilitation outcome and the cost of the intervention. If a setting has highly paid staff and expensive facilities, it does not necessarily produce better rehabilitation outcomes. (Perhaps better tennis players, but not better outcomes!)

A variable contributing to the lack of relationship between cost and outcome is the fact that expensive forms of psychotherapy may not produce more symptom improvement than can be achieved by chemotherapy alone. Neither type of treatment has been shown to have much effect on function. When psychotherapy is given to long term patients, it may increase the cost of treatment but not necessarily the outcome (Grinspoon, Ewalt and Shader, 1972). For example, a study of the social disability of patients one month after discharge from a number of different hospitals found no relationship between hospital per diem costs and the patient's social adjustment. As a matter of fact, ex-patients of the hospital with the highest per diem rate were less adjusted socially than ex-patients from the hospital with the lowest per diem rate (Walker, 1972).

It would seem that, based on what can be learned from history, proponents of a rehabilitation approach within the mental health system should not cite reduced costs as a reason for adopting a rehabilitation approach. A comprehensive well-run rehabilitation approach should produce additional dient benefits, but it might also produce additional or at least different types of costs.

Summary

As the psychiatric rehabilitation field moves into the future, there are a number of myths that can be d i sca rded-myths that have retarded development of the field of psychiatric rehabilitation. It is not surprising that most of the research showing these fifteen statements to be myths was conducted one to two decades ago. The lag time between the accumulation of new knowledge in mental health and its application to practice is usually considerable.

By throwing overboard this mythical baggage we can set a course toward future innovation, as there is still so much we need to learn about psychiatric rehabilitation. In the present, we need to put into practice the many things we do know. In the past, operating from a basis of myths, we acted as if we knew a lot more than we actually did! For example, we acted as if where a person was treated was more important than how, that drug treatment could singularly effect rehabilitation outcome, that the helpers' credentials were more important than their skills and attitudes, that a psychiatric diagnosis was a useful and prescriptive tool for rehabilitation, and so on. Free from this myth mak- ing, the present state of rehabilitation can focus specifically on its mission, i.e., helping persons who have experienced a psychiatric disability function in the living, learning and working environments of their choice, with the least amount of intervention by the helping professions.


The time has come for psychiatric rehabilitation to take its place as a recog- nized, credible treatment approach, integrated with existing treatment modalities. Psychiatric rehabilitation is complementary to current treatments, and should be viewed as an additional source of treatment effect in the mental health practitioners' repertoire.

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psychiatric rehabilitation: past myths and current realities

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