Recovery from Disability: Manual of Psychiatric Rehabilitation

This textbook, written by an acknowledged master in the field, is a tour de force. There is nothing one might wish to know about modern psychiatric rehabilitation that is not included, to a greater or lesser extent, in this work—from a page and a half on the psychosocial clubhouse model to nearly 90 pages on involving families in treatment; a section on tackling stigma to a chapter on vocational rehabilitation; and a reference to the importance of accurate diagnosis to a detailed description of social skills training, its application, and its weaknesses.

Liberman has written a comprehensive work, which will be readily understood and appreciated by anyone working with people with serious mental illness, regardless of his or her level of training. Even a rehabilitation specialist with years of experience will learn something from the last chapter on new developments in the field. Every reader should find joy in the author’s down-to-earth style and his stand against conformity. He warns us, for example, that the terms “recovery” and “recovery-oriented” can be used as catchphrases to cover real deficits in service provision. He rejects the ubiquitous term “consumer” as an ineffective way to empower patients and the often-heard “survivor” as stigmatizing service providers. He similarly discards “case manager” as being too impersonal. Liberman goes to some lengths to define what he and his colleagues view as “recovery,” a task the Remission in Schizophrenia Working Group shied away from as being too challenging (1). For Liberman, “recovery” requires a 2-year period of sustained remission of symptoms; engagement in productive activity, like work or school; independent management of day-to-day needs; cordial family relations; involvement in recreational activities; and satisfying peer relationships. These objective features, nevertheless, should be coupled with the subjective experience of hope, empowerment, peer support, and decreased internalized stigma. He points out, however, that a purely subjective approach to defining “recovery” may be divorced from generally accepted objective criteria.

Liberman concludes that attempts to define “treatment” and “rehabilitation” as separate entities are futile as the two are so closely intertwined. Pharmacological and psychosocial interventions must be integrated to obtain good outcomes. Neglect of the patient’s peer support needs and failure to engage with the family are likely to impede recovery, and the author rails against service providers who fail to solicit information from family members out of a misunderstanding of the nature of confidentiality in the treatment relationship. Moreover, as psychiatry increasingly recognizes the importance of cognitive deficits in psychosis as a dimension on a par with positive, negative, and affective symptoms, we shall have to look more and more to cognitive rehabilitation and remediation as necessary components of treatment.

Liberman’s book reflects the advances in U.S. rehabilitation, which have been accomplished within the past few decades, when American innovation in the field has been particularly important. He pays some attention to non-American models, providing a thoughtful description, for example, of the British integrated mental health care model, which is an appropriate adaptation of the assertive community treatment model for the health care system in the United Kingdom, where primary care physicians assume many of the tasks usually handled by psychiatrists in the United States. His coverage of a vocational approach, which has developed vigorously outside the United States—the consumer-employing social firm (or affirmative business) model—is, however, rather weak and outdated.

Liberman emphasizes something that is not commonly taught in professional schools and is sometimes realized only after a lifetime of work in the field—that evidence-based treatment alone is not sufficient; it has to be coupled with an appropriate set of values. As Liberman writes, “Values without effective treatments are abstractions, glittering generalities, and rhetoric. Effective treatments without values are sterile and insignificant” (p. 551).

We cannot do much better than to carry away from this book some of the values that Liberman cherishes: communicating optimism; instilling hope in the individual and his or her family; conveying respect and concern to our patients; reinforcing their sense of dignity; partnering with them in the treatment process to increase their self-responsibility; working with them to achieve a meaningful and purposeful life; and using humor to make the road to recovery fun. We should recognize, as he does, that empowerment of the individual, engagement of the family, and patience and perseverance are essential aspects of effective treatment. And, above all, we must recognize that the treatment of people with serious mental illness does not stop at the office door.