Psychiatric rehabilitation offers a number of models, refined over decades of research and practice, that aim to improve the social inclusion of people with mental illness and to reduce the symptoms of illness and the handicaps they produce. The rehabilitation field, however, is more than a series of programs: the approach is based on a set of values or principles that we have inherited from 200 years of social psychiatry. These principles, set out in the table to the right, have been “rediscovered” in several social movements in psychiatry over the past two centuries, the latest being the Recovery Model. The fact that these values have been rediscovered on several occasions makes it clear that they have been periodically abandoned, so we need to understand how critical these values are to the work that needs to be done. The very best treatment approaches available will not thrive in a therapeutic setting that neglects the values on which they are based.
Moral management, made vivid by the images of Pinel striking the chains from the in-mates of the Bicêtre asylum in 1793, but better illustrated by William Tuke’s contemporaneous development of the York Retreat, brought us the principle that patients’ self-control can be enhanced by minimal use of coercion, by respectful treatment in a home-like environment and by rewards rather than punishment. The approach generated great optimism in the early 1800s that early treatment in a properly constructed environment would result in a large number of cures. These principles of moral management were lost during the late nineteenth-century era of large asylums, but the consumer-driven US mental hygiene movement of the 1920s reintroduced the notion of therapeutic optimism, established institutional reforms, and demonstrated the importance of collaborating with leaders in many branches of community work, such as religion, education and law.
The Great Depression forced a return to confinement in ever larger institutions, but the post-WWII northern European social psychiatry revolution, that preceded the introduction of antipsychotic drugs, precipitated many important new developments – unlocking the asylum doors, abolishing mechanical restraints, and demonstrating the advantages of work therapy and early discharge from hospital. Psychiatrists in Britain introduced the “therapeutic community” into hospital wards across the country. Under this approach, staff shared power with patients in the running of hospital wards, nurses abandoned their uniforms for everyday wear and staff and patient roles became less distinct. As a result, the concept of patient empowerment was introduced into psychiatry. Interestingly, the same approach was simultaneously and independently introduced into community practice in New York City. Fountain House, the first psychosocial clubhouse was founded in New York in 1948 by ex-patients of Rockland State Hospital. Clubhouse members and staff worked together to operate the program, creating, in the process, an institutionalized approach to empowering people with mental illness which was to long outlast the hospital-based therapeutic community model. The 1990s witnessed an explosion of the number of psychosocial clubhouses, both in America and around the world, and the introduction of another consumer-driven psychiatric social movement – the Recovery Model – a central feature of which is empowerment. Let’s take a closer look at the influence of the Recovery Model and at the value of the psychosocial clubhouse.