Rehabilitation Services

ORGANIZING REHABILITATION SERVICES

The ideal rehabilitation service provides a comprehensive, continuous, coordinated, collaborative and patient-oriented approach. Interventions are linked to individualized needs assessments and to the personal goals of patients, each step negotiated and aiming at end-points that are personally meaningful and desired.

A key aspect of effective rehabilitation is the recognition that peoples’ behavior varies substantially from one situation to another. In general, task performance is more stable than social behavior, and simple skills are more transferable than complex ones. Many of the improvements seen in a narrow rehabilitation setting are transient responses to the particular characteristic of that environment and do not readily transfer or generalize to more complex settings and situations. Therefore, rehabilitation assessment should focus more on an individual’s capacities rather than fixed behaviors and should ideally be carried out across a wide spectrum of settings and conditions, in an attempt to work out what may be achieved under optimal conditions and what problems are likely in suboptimal conditions. People should be prepared for the environments in which they will be expected to function, and in general it is better to rehabilitate in the real situation than in the contrived setting of the hospital clinic.

It is also worth distinguishing long-term targets from short-term goals. The former are often couched in fairly broad terms, whereas the latter are the stepping stones to take the person where they want to go. Short-term goals need to be ‘SMART’ (specific, measurable, achievable, realistic and time-limited) and set in collaboration with the patient, relatives and other relevant people. With these short-term goals in mind specific interventions can then be devised that aim to produce a series of consistent, if modest, achievements backed up by frequent praise, encouragement and support.

It is important to emphasize the individual’s positive capacities and achievements, not only for the good this does self-esteem but also as ‘the most effective antidote to the paternalistic attitudes that develop when psychiatric services try merely to care for long term patients’.

The judicious combination of pharmacological and psychological treatments is, of course, an essential ingredient of rehabilitation practice. These topics are covered in detail elsewhere in this volume. Here we will just outline important approaches to treatments that will reduce impairment and disability and services that address key areas of handicap, housing and employment.