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date: 22 August 2017

Rehabilitation Groups

Summary and Keywords

“Rehabilitation groups” refers to community-based organizations which substantially rely on the work of volunteers to assist people with disabilities towards functional independence. One may differentiate between rehabilitation groups and clinical healthcare services by categorizing clinical services as being predominantly concerned with treatments designed to lower symptoms and cure ill health. Alternatively, rehabilitation groups focus their attention on delivering programs designed to assist people in regaining “functional independence” with or without the ongoing presence of symptoms. Common programs rehabilitation groups deliver are described as including but not being limited to the following:

• Mental health rehabilitation: assisting people with lived experience of mental illness towards social and emotional wellbeing.

• Drug and alcohol rehabilitation: facilitating recovery from abuse of and dependency on psychoactive substances such as alcohol and other drugs.

• Physical health rehabilitation: improving physical and/or neurocognitive functions that have been diminished by ongoing effects of disease or injury.

Major themes of communication influence rehabilitation groups and there are connections between the daily work of rehabilitation groups and the theoretical paradigms that influence them. Theoretical paradigms include social disability theory, recovery-oriented care, person-centered care, and cultural materialism.

Keywords: rehabilitation groups, disability, mental health, physical health, substance abuse, communication, risk, theory

Introduction

The term “rehabilitation” has become synonymous with a wide range of services and programs. In this chapter, the term “rehabilitation groups” is used to refer to community-based organizations which substantially rely on the work of volunteers. Rehabilitation groups aim to assist people who experience disability by pooling their available resources and using them to enhance the functional independence of the people they serve. This approach differs from clinical healthcare services, which focus on delivering treatment designed to cure an illness or lower symptoms.

To get a clearer picture of the difference between rehabilitation and clinical treatment, consider a person who experiences back pain due to a bulging disc in their lower back following a motor accident. A doctor in a clinical service would typically diagnose the injury, prescribe analgesia, and refer to a surgeon for surgery, in an effort to try and cure the problem. Supposing that following surgery there was no improvement in mobility, the surgeon would then begin the rehabilitation phase by referring to a physiotherapist in order to assist the person towards the highest level of physical mobility possible after the deficits caused by the accident. In the longer term, an occupational therapist may also make a home visit, suggest a mobility rail be added to the shower and kitchen of the person’s home, and identify that the person may have developed depression due to their chronic lower back pain and inability to return to work. The person may then be referred to a psychologist and a rehabilitation employment specialist for counseling and vocational support. In this example, the work done by the doctor and the surgeon would be referred to as “clinical treatment.” Subsequent services delivered by the physiotherapist, occupational therapist, psychologist, and employment specialist would be described as “rehabilitation” services because they are aimed at assisting the person back towards their best level of function possible despite ongoing symptoms of injury.

The goal of functional independence therefore differs from the goal of treatment and cure. Common services that rehabilitation groups deliver include but are not limited to the following:

  • Mental health rehabilitation: assisting people with lived experience of mental illness towards social and emotional wellbeing.

  • Drug and alcohol rehabilitation: facilitating recovery from abuse of and dependency on psychoactive substances such as alcohol and other drugs.

  • Physical health rehabilitation: improving physical and/or neurocognitive functions diminished by ongoing effects of disease or injury.

Major themes of communication often influence rehabilitation groups. A tension exists between the work of rehabilitation groups and the theoretical frameworks used to guide them. As theory is open to interpretation and should be tested against alternative explanations, an exploration of these tensions in a variety of theoretical paradigms sheds light upon the many dimensions of rehabilitation groups.

Discussion of the Literature

In the 21st century, there are increasing numbers of people who are living longer with disability. This means the need for rehabilitation groups is increasing internationally. In the United States, the Americans with Disabilities Act of 1990, amended in 2008, defined disability as “a substantial limitation in a major life activity.” Alternatively, the World Health Organization defines disability as “an inability to participate or perform at a socially desirable level in activities such as self-care, social relationships, work, and situationally appropriate behavior” (Üstün et al., 2010).

A recent measurement of disability burden found that the world’s most common cause of disability is mental illness (Murray et al., 2013). People with mental illness often experience higher rates of chronic physical health and substance use problems than the general population (Happell et al., 2011; Hunt, Siegfried, Morley, Sitharthan, & Cleary, 2013). They also experience higher rates of unemployment (Harvey, Modini, Christensen, & Glozier, 2013), incarceration (Baksheev, Thomas, & Ogloff, 2010), and homelessness (Baggett, O’Connell, Singer, & Rigotti, 2010; Moore, Gerdtz, & Manias, 2007). Studies related to the financial cost of mental illness have found that in the United States, anxiety disorders alone cost $42 billion annually and substance use disorders cost a massive $500 billion every year (Kazdin & Blase, 2011). When the burdens of the wide range of physical health conditions that cause disability are added together, it becomes clear that the complex mix of challenges that rehabilitation groups respond to is immense. Health systems and approaches to rehabilitation vary considerably throughout the world. It is important to recognize, however, that there have been some key historical moments that have had a powerful influence on the development of modern-day rehabilitation groups.

The end of WWI left large numbers of returned soldiers to cope with a wide range of disability, mental health, and substance use problems. In 1921, a group of veterans who had become blind during the war formed the American Foundation for the Blind (AFB) (Pfeiffer, 1993). This organization highlighted the plight of people with long-lasting health problems in a way that the wider society was willing to support. Despite the emergence of groups such as AFB, however, a political ideology known as eugenics became prominent for much of the first half of the 1900s (Porter, 1999).

Eugenics suggested that people with disabilities or mental illness should be eradicated from society. From the 1920s to the 1960s, the influence of this ideology led to government policies that facilitated the involuntary sterilization of more than 60,000 people with physical and mental disabilities in North America. Eugenics was also used by the Nazi regime in Germany to justify the extermination of more than 200,000 disabled people during WWII (Kühl, 2002).

In spite of the influence of eugenics and in the midst of the Great Depression, the 1930s witnessed the emergence of what has become the world’s most prolific substance use rehabilitation group, Alcoholics Anonymous (AA). Established in 1935 by a group of people who shared a history of alcoholism, today AA has over 2 million members who gather in more than 160,000 support groups throughout 150 countries worldwide. The success of AA has inspired the development of many other rehabilitation groups in the field of substance use rehabilitation. Some of these include Overcomers Outreach, Celebrate Recovery, Women for Sobriety, and Rational Recovery (Kurtz, 2010).

Following the Great Depression of the 1930s, the psychosocial Clubhouse model of rehabilitation was established in 1948 (Beard, Propst, & Malamud, 1982). A group of people with lived experience of mental illness who had been released following the closure of many old psychiatric asylums started to meet together on the steps of the New York Public Library, supporting one another in their transition into life in the community. The value of the group was recognized by a local philanthropist who gave them a house for their meetings. In turn, this led to the establishment of a service known as Fountain House (because of the fountain in the backyard of the house). Today referred to as the “Clubhouse Model of Psychosocial Rehabilitation,” there are now over 300 Clubhouses based on the Fountain House approach that support the rehabilitation of people with mental illness in more than 30 countries worldwide (Raeburn, Halcomb, Walter, & Cleary, 2013).

A proliferation of rehabilitation groups following WWII accompanied other big social changes such as the civil rights, women’s rights, and antiwar movements. The wave of social change led to powerful political advocacy for people with physical disabilities. This change resulted in passage of the Rehabilitation Act of 1973, containing Sections 503 and 504, which broadened the concept of who could benefit from rehabilitation, prohibited discrimination in federally funded programs, and promoted affirmative action for employment of people with disabilities (Pfeiffer, 1993). Since the International Year of Disabled Persons (IYDP) in 1981, rehabilitation groups in all fields have developed at a rapid pace and their influence continues to expand globally.

Rehabilitation groups have the potential to assist people with disabilities and to enhance the wellbeing of whole communities by improving levels of satisfaction, employment, and productivity. In spite of this, rehabilitation cannot occur without risk, because anytime a person seeks to improve their health, they take risks. These risks may be relatively small, such the risk of failing to reach a particular physical activity goal, or the financial risk of paying a provider for assistance that may or may not successfully address a health problem. Similarly, individual staff and organizations set up to provide rehabilitation services also take risks. These commonly include staff members’ investment of time and effort to design programs that may or may not attract ongoing funding, or organizations’ investment in equipment that may or may not enhance the programs that they deliver.

Communication regarding health and risk is therefore a crucial part of what occurs in processes that enable rehabilitation groups to deliver services. Having said this, it is essential that concerns about risk do not compromise the ability of clients, staff, or organizations to stay committed to rehabilitative processes. Within rehabilitation groups, the tensions around rehabilitation, health, and risk are commonly negotiated through client, staff, and organizational dimensions.

Client Dimension

Modern rehabilitation groups employ consistent messaging around the idea that the most important party in the rehabilitation process is not the organization or staff involved, but the client. Traditional ideas of health professionals as “experts” ready to fix or cure illness have been replaced in modern-day rehabilitation by the notion of staff as trained professionals who are willing to form coaching partnerships with clients in order to facilitate recovery. Clients are therefore encouraged to believe that although they may be accessing assistance, their destiny lies in their own hands with regards to making any kind of rehabilitative effort. Change is hard, but clients are encouraged that they can achieve it, and to keep trying.

While this emphasis on the ability of individual clients to have substantial impact on their rehabilitation may appear empowering, it also serves to alleviate any distress or disempowerment staff or the rehabilitation group may experience if rehabilitation is unsuccessful. Research evidence strongly suggests that higher-intensity rehabilitation programs lead to improved recovery across physical and mental health populations (Kwakkel, Wagenaar, Koelman, Lankhorst, & Koetsier, 1997). Meta-analyses reviewing the effects of physical rehabilitation for victims of stroke found that substantial improvements could be achieved with high-intensity rehabilitation (Langhorne, Wagenaar, & Partridge, 1996). Such evidence is currently used to promote up to three hours of therapy five days per week in many North American physical rehabilitation programs. Despite such evidence, because rehabilitation groups have a strong reliance on volunteers, they are seldom able to access resources required to deliver intensive therapies. In order to address this challenge and differentiate themselves from the sort of services that well-funded state-owned or privately run organizations can produce, rehabilitation groups employ a wide range of theoretical paradigms to inform the delivery of their programs and communicate with clients. Two common modern paradigms are social disability theory and recovery-oriented care.

Theoretical Paradigms: Social Disability Theory and Recovery-Oriented Care

Social disability is the dominant framework used by physical health rehabilitation groups (Shakespeare, 2006). This theory challenges the traditional biomedical view that social restrictions for disabled people are a consequence of physical dysfunction. Instead, social disability theory contends that people with impairments are disabled more by social systems than by their bodies. According to this theory, disability is not the outcome of physical pathology but of social organization. The built environment, for example, is built for non-disabled people, and the norms of construction are such that those with physical differences are often excluded from a whole range of social spaces that non-disabled people take for granted (Goodley, Hughes, & Davis, 2012).

Social disability theory is commonly communicated in rehabilitation groups in the form of education. In this way, rehabilitation staff position themselves as reservoirs of knowledge about physical, psychological, and social wellbeing. Information conveyed is drawn from what is promoted as being “evidence-based” research, in order to enhance clients’ social, emotional, and physical worldview.

In the field of mental health and substance use rehabilitation, groups have increasingly been adopting what is referred to as a “recovery-oriented” approach built around a “personal recovery” paradigm (Pelletier et al., 2015). The concept of personal recovery emerged from the mental health consumer movement that developed in the second half of the 20th century, to advocate for the rights of people who experience mental illness. According to this theory, mental health recovery is more about a personal developmental journey, rather than just a disease in need of clinical treatment (Jacobson & Curtis, 2000; Warner, 2010). There is no single definition of personal recovery; however, one of the most commonly used explanations was written by Anthony (1993), who described it as

A deeply personal, unique process of changing one’s attitudes, values, feelings, goals, skills and/or roles. It is a way of living a satisfying, hopeful, and contributing life even with limitations caused by the illness. Recovery involves the development of new meaning and purpose in one’s life as a person grows beyond the catastrophic effects of mental illness. (p. 15)

Started by people who began writing and publishing their personal experiences of recovery such as Deegan (1988) and Leete (1989), a large body of writing validating the concept of personal recovery has developed. In 2011, Leamy and colleagues (2011) undertook a systematic literature review to identify experiences commonly associated with personal recovery. After screening over 5,000 papers, the authors identified five processes common in personal recovery. They were connectedness, hope and optimism, identity, meaning in life, and empowerment (Leamy et al., 2011).

Using the Built Environment to Empower

Health and wellbeing are enhanced when people feel they have the ability to control the built environment around them (Evans, 2003). In spite of this, healthcare policy often includes debate regarding the efficacy of providing places to assist people with complex needs, because providing them can cost substantial amounts of money to establish and maintain. In contrast, programs that are essentially theoretical can be published in book- or Internet-based formats and distributed to a much wider audience. Despite this, what book- and computer-based programs lack is physical space—they therefore depend heavily on the motivation of individuals to engage with them. For people with disabilities, such theoretical programs can be difficult to persevere with.

Rehabilitation groups often employ built environments to facilitate participation of clients within their programs. For example, a rehabilitation service designed for people with intellectual disability may commonly use a large number of whiteboards scattered throughout every room of the rehabilitation building. Whiteboards are used to encourage participation of clients in meetings, to model organized behavior, and also to act as an easily visible daily plan for clients and staff. Group meetings between staff and clients take place around whiteboards, and clients are encouraged to participate by sharing ideas or acting as scribes for such meetings. The names of people participating in the rehabilitation program that day are recorded, and by using whiteboards to facilitate such meetings, the staff continually reinforce the importance of planning and organization.

For people who have not experienced living with intellectual disability, the idea of participating in a group meeting, having their name recorded on a whiteboard, and being made responsible for a task may seem incidental. However, people who attend such rehabilitation groups have often experienced stigma, injustice, and loss of face. This means that having access to dependable relationships, having their name publically recorded as being responsible, and having their views being counted as important can rebuild self-esteem, trust, and confidence.

Staff Dimension

Interactions between staff and clients within rehabilitation groups are wide and varied. Methods include but are not limited to physical therapy, counseling, education, role playing, working through hypothetical examples, exposure, and group participation. Sometimes, rehabilitation workers may increase an individual’s motivation not only by making their program fun and engaging, but by providing rewards for involvement in activities. For example, collaborating with clients, staff might design a reward system for reinforcing involvement such as a token or point system whereby points are exchanged for a small reward. Regular praise and encouragement are used to shape participation in the program.

Theoretical Paradigm: Person-Centered Care

A theoretical framework referred to as “person-centered care” is often used by rehabilitation groups to emphasize the importance of placing the interests and wellbeing of their clients first. In rehabilitation groups, this means that staff are encouraged to make clients’ stories and strengths the centerpiece of action. This idea promotes an approach whereby the client is treated as the teacher, and the staff (volunteer or paid) assume the role of student. Staff are taught to identify clients’ strengths and to appreciate clients as people rather than as a set of challenges or symptoms to be fixed (Ekman et al., 2011).

Staff are encouraged to develop creative responses to the strengths and circumstances of individual people. For example, if an individual in a drug and alcohol rehabilitation program were having trouble developing cannabis refusal skills, staff would be encouraged to consider alternative ways to empower the client to develop the skills that better match the client’s level of understanding (Kitson, Marshall, Bassett, & Zeitz, 2013). Just as likely are cases when people grasp certain concepts or skills very quickly. In such cases, rehabilitation groups seek to adjust so that they deliver services and programs according to each individual’s pace.

One of the biggest factors influencing how comfortable clients are within rehabilitation groups is how comfortable staff members are with themselves. They are encouraged to be aware of their own body language and the body language of clients. Body language is then used as clues regarding how interactions are proceeding, how the client is feeling, and how they feel about staff. Because rehabilitation groups interact with a wide range of people from a variety of cultures, workers are encouraged to be aware that different cultures use and interpret body language in different ways. For example, for indigenous Australians, a low amount of eye contact may be normal, while people from a Greek background may find this offensive.

Self-Care

In the field of rehabilitation, it is important to challenge workplace cultures that encourage staff to wear a state of chronic stress as a badge of honor. When all the complex issues rehabilitation groups juggle every day are considered, sometimes it seems easier to try to ignore frustrations and just get on with the job. But chronic states of stress can catch up quickly, and if this happens, the quality of services can suffer.

People who work in rehabilitation groups are therefore encouraged to think about ways to maintain resilience in the long term. Developing optimum self-care habits is promoted as being effective in improving the quality of rehabilitation workers’ lives and the quality of services they are able to provide. With regards to workplace productivity, self-care habits are said to empower workers to

  • Not to gain weight as easily as people who are overtired

  • Make more reasoned decisions

  • Have lower blood pressure

  • Have a stronger immune system

  • Be more productive

  • Stay employed longer

Experienced rehabilitation workers appreciate that self-care is a unique process. One worker may find the best way to improve her health is to take a 20-minute nap during lunch break, another may find it’s more effective to take a long walk with his dog at the end of a shift, while still another may believe that meditation and painting are the secret. Looking after self and building strong relationships are essential components of high-quality rehabilitative groups.

Case Study: Psychosocial Clubhouse Model

The Clubhouse model of psychosocial rehabilitation is the world’s most widely used type of mental health rehabilitation group. In line with international research, Clubhouses have a strong focus on the value of work in mental health recovery. This is facilitated through a daily timetable referred to as the “work-ordered day.”

Following the timetable of a typical working week, people with a history of mental illness are provided with the opportunity to work as volunteers alongside paid staff in the delivery of business, hospitality, and vocational and social programs. People who access Clubhouses are considered “members” of the organization. In this way an increased level of equanimity is engendered as people with mental illness are treated not as “recipients” of care with titles such as “patients,” “clients,” or “consumers,” but as “members” who are encouraged to collaborate with staff in the development and delivery of programs. In accordance with Clubhouse rules, Clubhouse rehabilitation centers have no separate staff room or office of any kind. This means that apart from a few confidential administrative roles played by the Clubhouse director such as paying staff wages, there are no activities that are purely a “staff” or “member” domain. Clubhouse’s focus on the rehabilitative potential of work activities means that staff interactions with members seldom focus directly on the experience of mental illness. Instead, interactions normally occur in opportunistic work-focused contexts. This means that Clubhouse staff interact with members while working alongside them on tasks ranging from basic cleaning duties through to advanced fundraising strategy and leadership meetings. This flat organizational approach to delivering programs allows staff to coach members to build vocational skills.

Another striking quality is that Clubhouse staff are not coercive. Instead staff extend accepting and trusting attitudes that stand in contrast to many members’ experiences in other services, where they reported feeling being forced to attend and/or participate in certain activities. The non-coercive nature of the service is particularly evidenced by efforts of staff to encourage and cultivate the voice of members. While this may seem like common sense, several studies have indicated that encouraging the views of consumers is unusual in healthcare, where higher value is often placed on the views of staff and the objectives of services than on engaging with and supporting the goals of the person experiencing illness. The Clubhouse approach therefore contrasts with historically disempowering and coercive practices that tended to pressure people to repress their voice in order to avoid negative consequences (Pernice-Duca, 2010; Raeburn, Schmied, Hungerford, & Cleary, 2016).

Organizational Dimension

The business side of rehabilitation is not often a publicized focus of rehabilitation groups. On the rare occasion that they do mention business or financial affairs, it is often communicated as being a concern with funding bodies, government, administrators, or financial institutions. Perhaps due to their reliance on volunteers, rehabilitation groups often lament and lobby regarding a lack of funding and how this compromises service delivery.

Theoretical Paradigm: Cultural Materialism

A cultural materialist paradigm asserts that the business and financial affairs of rehabilitation groups are central to what they deliver. Materialist theory suggests that rehabilitation groups, although they may be heavily reliant on volunteers, are in essence an entrepreneurial activity undertaken by groups of people who can afford the time and money to do so. According to this theory, rehabilitation groups’ purposes go beyond the provision of “recovery-oriented” or “person-centered” care, since they are also strongly influenced by the material conditions of the people who deliver them. A materialist view of society suggests that philosophical and social change, such as that brought about by rehabilitation groups, is essentially linked to changes in technology, social stratification, and politics, and that these dimensions mold production and reproduction (Harris, 2001).

This theoretical perspective therefore suggests that rehabilitation groups’ attempts to assist people with disabilities are directly linked to the usefulness of rehabilitation clients in a productive process and that the services delivered by rehabilitation groups are influenced by class, status, sex roles, and labor dynamics. Of course, there is no question that rehabilitation groups are also motivated by beliefs and values other than financial concerns, but this theory is a reminder that they are significantly affected by them.

Cultural materialist theory allows for the operation of any number of causes besides technological, environmental, and production-related forces. Rehabilitation groups in similar socioeconomic circumstances, therefore, will not all deliver care in the same way; rather, numerous other ideologies and social factors may influence how they are organized (Glenn, 1988). Despite this, no matter what ideology motivates a particular rehabilitation group, materialist theory would suggest that in a large number of instances, material forces will be strongly influential. Despite their reliance on volunteers, it is not only humanistic recovery-oriented or person-centered approaches that determine the care delivered by rehabilitation groups—money also has a strong role to play. In general, it is access to money that allows anybody to volunteer. In the future, rehabilitation groups will need to be prepared to expand their concern to factors related to the economic, technological, and environmental facts that contextualize the services they deliver. In this way, rehabilitation groups may gain a broader understanding of how to develop the rehabilitation services needed in the 21st century.

Delivering Safe Practice

All rehabilitation groups have a responsibility to take practical steps to ensure that employees and volunteers are safe at work and eliminate, isolate, or minimize exposure to hazards. Rehabilitation groups need to provide appropriate and safe equipment and facilities to ensure that work methods do not harm employees. A common approach to health and risk messaging at the organizational level of rehabilitation groups is to design a risk management framework.

A risk management framework provides a systematic overview of all the elements that require risk management within the rehabilitation group. The framework applies to all service participants, as all have a role to play. Staff and volunteers in non-management roles are encouraged that they play a vital part in protecting resources, their colleagues, clients, and the public from loss, abuse, or injury by adopting a “risk-aware” attitude. Staff and volunteers are charged with being systematic in the way they manage resources. They achieve this by scoping out the organizational terrain to ensure that existing and threatened risks are identified, understood, and dealt with in a deliberate manner. Common stages of organizational risk management can be easily remembered by using the acronym SCOPE, which stands for

  • Survey environment

  • Create contingency plan

  • Operationalize

  • Probe

  • Evaluate

“Surveying the environment” means identifying and documenting the strategic, operational, and organizational context in which risks are likely to occur. Criteria against which risk will be evaluated throughout a therapeutic group’s service sites are established, and a structure for a contingency plan is developed. As part of this process, it is helpful to identify key stakeholders, any relevant legislation, and organizational policies and procedures, as well as political, economic, and social issues that may impact on risk. The process is sensitive to the individual organization’s mission, vision, and strategic plans and sets the scene for the level of resources it is prepared to commit to managing risk. Within most organizations, this process is delegated to a management committee. Committees within rehabilitation groups commonly include a mixture of managers, paid staff, and volunteers. They assume responsibility for understanding the context and establishing the principles that guide risk management processes.

“Contingency plan” involves identifying and documenting all reasonably foreseeable risks in a clear, structured manner. Risks that remain unidentified may pose a significant threat to programs within rehabilitation groups and impact on the ability of clients to achieve their recovery goals. On the flipside, unidentified risks can also lead to missed potential opportunities. For these reasons, risk management committee meetings should encourage and enable committee members to speak freely, thereby enhancing the quality of any contingency plans.

“Operationalizing” refers to putting the contingency plan into action. Options may include paying a third party to insure against risk, such as professional and public liability insurance. In some circumstances, an organization’s ability to insure against risk may be disproportionate to the potential benefit gained. In such instances, some risk may need to be accepted. A common example may include potentially violent clients; rehabilitation groups may recognize such risk and choose to tolerate it by implementing management practices. Overall, most risks will be able to be contained at an acceptable level. Actions referred to as “internal controls” may be operationalized within the rehabilitation group, to contain risk (such as the risk to existing services) while focusing on growth. Risk management is therefore operationalized by using a wide range of management solutions.

“Probing” is about checking the operationalization processes as it proceeds. This involves asking specific, probing questions, such as the following:

  • What actions had the desired effect?

  • Did anything go wrong during the process?

  • Did the process shed light on any new risks or raised any operational questions?

In this way, a comprehensive list of all risks can be compiled, which will assist evaluation.

“Evaluation of risk” involves a comparison being made between outcomes of operationalizing the contingency plan and the levels of risk previously identified as part of the survey of the environment. This results in a risk ranking or priority listing for all risks across a full range from high to low. Those with a low ranking may fall into an acceptable risk category. Finally, the cycle begins again with a new survey of the risk environment and development of a fresh contingency plan.

Ongoing cyclical management of risk within rehabilitation groups is very important because it reflects the fact that as services are delivered risks evolve, and new risks emerge all the time. Risk management is therefore not a finite activity but must be done on the basis of continuous improvement. It allows changes in the risk environment to be incorporated into the risk management cycle. The board of the rehabilitation group should ensure regular reporting by the risk management committee.

Rehabilitation Groups, Risk, and Social Welfare

There is a substantial body of research that suggests a major disincentive for people who engage in rehabilitation to pursue paid employment is workplace stigma and discrimination (Brohan & Thornicroft, 2010; Hanisch et al., 2016; Krupa, Kirsh, Cockburn, & Gewurtz, 2009). Stigma towards people who experience disability can influence workplace considerations such as intention to commence employment, access to promotions, numbers of sick days taken, and early retirement. It can also negatively affect help-seeking behavior and have a range of adverse effects on workplace peer relationships (Hamann, Mendel, Reichhart, Rummel-Kluge, & Kissling, 2016).

Ironically, another disincentive that can influence people with disabilities interested in paid employment is sometimes created by government welfare systems. In Australia for example, adults with a history of mental illness such as schizophrenia are able to access a welfare payment known as the disability support pension (DSP) (King et al., 2006). The DSP provides long-term biweekly cash payments along with subsidized rent and public transport benefits. For a variety of reasons, such as low levels of education and episodic employment histories, many people who are unemployed with disabilities are often only able to access low-paying jobs. This means that people with mental illness who currently access the DSP, but who are interested in paid employment, are faced with a difficult predicament. Even if they secure paid work there is often little or no financial benefit in doing so (King et al., 2006; Waghorn et al., 2012). This is because taking up employment on a low-level wage means they lose access to their DSP payment and need to enter the private rental market. This commonly has other implications, such as having to move premises to find affordable rent and travel long distances to and from work.

Societal barriers to well-paid employment for people with disabilities, such as workplace stigma and the vagaries of the welfare system, highlight that rehabilitation groups are only one part of wider systems. While rehabilitation groups may successfully deliver quality services, unless societal barriers that prevent people with disabilities from participating as full citizens in the world are removed, functional independence and autonomy for many people will remain illusory.

Conclusion

A variety of opinions are expressed by theorists about how best to assist people who live with disabilities. Social disability and mental health recovery researchers such as Siebers and Slade (Siebers, 2013; Slade et al., 2015) suggest that addressing the attitudes of mainstream society, so that people with lived experience of mental illness can experience restoration of their human rights as full citizens, should be a major focus of recovery-oriented practice. A different perspective is expressed however, by theorists such as Mandiberg and Warner (2013) who, while agreeing that continuing to address societal attitudes and stigma towards people with disabilities is important, observe that attempts to reintegrate people with severe mental illness into mainstream society have been made for over 100 years without wide success. They argue that supporting people with lived experience of mental illness to form their own identity communities offers an approach where people can gain the sense of belonging and freedom they need to pursue personal recovery.

The notion of identity communities, made up of people who experience disability, resonates with the observation made by sociologist Richard Sennet (2011), that throughout history groups of oppressed people have formed communities in an effort to support each other in ways that challenge the predominant values of their culture. Reflecting on the experience of the Jewish community in 16th-century Venice, Sennett contends that things people are stigmatized for often become icons of their oppression, leading them to join with others who identify with their experience and form a community of cultural outsiders (Sennett, 2011).

In rehabilitation groups, access is generally made possible through identifying as a person with a lived experience of disability. In many respects this is countercultural, because having a disability in modern society continues to be widely associated with stigma and vulnerability. One of rehabilitation groups’ greatest assets is their ability to provide a sense of community, participation, and respect, thereby enhancing life satisfaction and wellbeing. Other healthcare services may well have much to learn from exploration of communication processes with rehabilitation groups.

Further Reading

Davis, L. (2013). The disability studies reader (4th ed.). New York: Taylor and Francis.Find this resource:

Deegan, P. E. (1988). Recovery: The lived experience of rehabilitation. Psychosocial Rehabilitation Journal, 11(4), 11–19.Find this resource:

Doyle, A., Lanoil, J., & Dudek, K. (2013). Fountain House: Creating community in mental health practice. New York: Columbia University Press.Find this resource:

Drew, N., Funk, M., Tang, S., Lamichhane, J., Chávez, E., Katontoka, S., et al. (2011). Human rights violations of people with mental and psychosocial disabilities: An unresolved global crisis. The Lancet, 378(9803), 1664–1675.Find this resource:

Goodley, D., Hughes, B., & Davis, L. (2012). Disability and social theory: New developments and directions. New York: Palgrave Macmillan.Find this resource:

Kendall, E., Buys, N., & Larner, J. (2000). Community-based service delivery in rehabilitation: The promise and the paradox. Disability and Rehabilitation, 22(10), 435–445.Find this resource:

Kurtz, E. (2010). Not God: A history of Alcoholics Anonymous. Minneapolis, MN: Hazelden.Find this resource:

Oliver, M. (1996). Understanding disability: From theory to practice. New York: St. Martin’s.Find this resource:

O’Mara-Eves, A., Brunton, G., McDaid, G., Oliver, S., Kavanagh, J., Jamal, F., et al. (2013). Community engagement to reduce inequalities in health: A systematic review, meta-analysis and economic analysis. Public Health Research, 1(4).Find this resource:

Pratt, C. W., Gill, K. J., Barrett, N. M., & Roberts, M. M. (2006). Psychiatric rehabilitation. Thousand Oaks, CA: SAGE.Find this resource:

References

Anthony, W. (1993). Recovery from mental illness: The guiding vision of the mental health service system in the 1990s. Psychosocial Rehabilitation Journal, 16, 11–15.Find this resource:

Baggett, T. P., O’Connell, J. J., Singer, D. E., & Rigotti, N. A. (2010). The unmet health care needs of homeless adults: A national study. American Journal of Public Health, 100(7), 1326–1333.Find this resource:

Baksheev, G. N., Thomas, S. D., & Ogloff, J. R. (2010). Psychiatric disorders and unmet needs in Australian police cells. Australian and New Zealand Journal of Psychiatry, 44(11), 1043–1051.Find this resource:

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Cross-References to Other Oxford Research Encyclopedia Articles

Addiction; Citizen Participation; Employment; Online Support Groups; Mental Illness; Recovery; Self-Help Groups; Social Welfare.