Patient-Centered Care and Psychiatric Rehabilitation:
What’s the Connection?
Melissa A. Hensley, PhD, LGSWAssistant Professor of Social Work
2211 Riverside Avenue South
Campus Box 51
Minneapolis, MN 55454
Hensley, M.A, (2012). Patient-Centered Care and Psychiatric Rehabilitation: What's the
Connection? International Journal of
Psychosocial Rehabilitation. Vol 17(1) 135-141
Keywords: health care, psychosocial rehabilitation, patient-centered care, recovery
should psychiatric rehabilitation practitioners take notice of the idea
of patient-centered care? After all, it seems to be updated
language describing the same old medical model of care provision, with
the physician in charge and everyone else, including the patient,
following in lock-step behind. Leplege et al. (2007) have noted
that psychiatric rehabilitation practitioners have studiously avoided
use of the term “patient-centered care.” This may be because of
the fact that patient-centered care does in some ways seem to keep the
doctor in charge, despite rhetoric about enabling and empowering
patients. The literature describing and advocating for the use of
patient-centered care has been dominated by physicians and others
working in medical settings, who refer to consumers of health care as
“patients” and seem to keep control of health care processes in the
hands of doctors. We in community mental health may see ourselves
as better than that—we put our ideas about empowerment into practice,
instead of just talking about them, right?
But why not embrace
patient-centered care? In reality, despite the use of the word
“patient,” which many in the mental health community dislike,
patient-centered care is a concept that gives primacy to the voice and
concerns of the person using the health care service. Some
commentators have made the observation that the mental health field is
as guilty as the rest of health care of taking decision-making away
from our clients and assuming that our clients cannot speak for
themselves (Pincus et al., 2007). Finn and Jacobsen (2003) have
noted that social workers in particular may be more likely to embrace
the language of empowerment than its actual practice. Perhaps we
would benefit from paying more attention to patient-centered care as a
way to structure and evaluate our practice.
We in community
mental health should make use of the idea of patient-centered care
because it stresses many concepts that are important to us in our
work. Noted scholars and advocates in health care have determined
that patient-centered care is as important and relevant to mental
health and substance use care as it is for physical health care (IOM,
2006). Adherence to patient-centered care has also been
associated with higher satisfaction and in some cases better outcomes
in terms of patients’ experience of physical symptoms and adherence to
care regimens (AHRQ, 2009). In spite of our disdain for the word
“patient” to describe those who use our services, there may be aspects
of this idea that could lend more integrity to what we do.
What is patient-centered care?
care is a way of planning, delivering, and evaluating health care that
focuses on the needs of the user of service first of all, as opposed to
focusing on the needs of the health care organization or provider (IOM,
2001). The term patient-centered care has its origins in
conceptual writings of the 1960s (Balint, 1969). Patient-centered
care in the 1960s was pioneered by psychiatrists working in the United
Kingdom, who were training medical students and general practitioners
to be more attentive to the emotional concerns of their patients
(Balint, 1969). Primary care practitioners in Canada developed
the idea of patient-centered care as a way of structuring
patient-provider communication, to pay attention to the person and
his/her experiences, not just the symptoms of the illness (Levenstein,
J. H., McCracken, E. C., McWhinney, I. R., Stewart, M. A. & Brown,
J. B., 1986). Developed in the early 1990s as a way of evaluating
inpatient hospital stays (Cleary et al., 1991), patient-centered care
has evolved into a system of ideas about how to deliver health care
that is united by a drive to meet the needs of the service user.
The Picker Institute (2010) has pioneered the use of questionnaires and
other evaluation tools to assess the degree of patient-centered care in
a variety of health care settings. Much of what motivates
patient-centered care is a desire to restructure health care services
so that service users truly feel that their preferences and needs are
respected, and so that health care outcomes are satisfactory not only
according to the provider’s definition, but according to the user’s, as
Why should community mental health practitioners care about this concept?
notion of patient-centered care is relevant to community mental health
professionals because it embodies many of the values and practices that
we claim to embrace but do not always practice consistently.
Patient-centered care offers a way to empower service users to take
more control over health care interactions, and it suggests ways to
restructure care to make the concerns of service users, not their
providers, the primary motivator of care.
One of the most
influential definitions of patient-centered care is that put forward by
the Picker Institute in their book, Through the Patient’s Eyes (Gerteis
et al., 1993). This definition offers eight principles of
patient-centered care and applies them to reform of health care
practices and systems. This paper will outline the eight
principles of patient-centered care as outlined in Through the
Patient’s Eyes (Gerteis et al., 1993) and apply them to psychiatric
rehabilitation practice, with particular attention to the formulation
of psychiatric rehabilitation practice as understood by Anthony, Cohen,
Farkas, and Gagne (2002). The congruence of patient-centered care
with Corrigan’s (2003) definition of psychiatric rehabilitation will
also be outlined. Following this will be a brief discussion of
patient-centered care with involuntary clients.
Patient-Centered Care: Application to Psychiatric Rehabilitation.
idea of patient-centered care should matter to psychiatric
rehabilitation practitioners. Although psychiatric rehabilitation
is not strictly a health care field, many of the professionals who work
in this context come from health care, such as nurses, physicians, and
occupational therapists. Psychiatric rehabilitation work is
frequently reimbursed by health care funding sources. Therefore,
even though patient-centered care reforms have mostly centered on
physical health care, there is still much for mental health
practitioners to learn.
Patient-centered care embraces respect
for the individual’s needs, preferences, and values. These are
important to psychiatric rehabilitation, as well. Psychiatric
rehabilitation practitioners strive to create individualized plans of
treatment that are based on the service user’s preferences and
values. More and more, treatment planning is becoming a
partnership—conducted in an atmosphere in which not only can
professionals respect the needs of the service user, but also create
conditions for the service user to assume and express his or her own
power. Anthony et al. (2002) discuss the primacy of partnership
with service users in Principle 6 of their textbook, Psychiatric
Rehabilitation: “Active participation and involvement of
individuals in their rehabilitation process is the cornerstone of
psychiatric rehabilitation (p. 85).” This principle aligns
smoothly with the patient-centered care value of respecting individuals.
communication, and education—this is another patient-centered care
principle. Psychiatric rehabilitation providers definitely
believe in open lines of communication between provider and service
user, as well as that service users should have unbiased, complete
information about their treatment options. As a part of this,
psychiatric rehabilitation practitioners often adopt the role of
educator. Education enhances treatment choices. For
example, service users should have information about the treatment
choices they are being offered, the evidence base behind the
treatments, and the expected outcomes of those treatments. This
makes the notion of choice more meaningful. Anthony and Huckshorn
(2008) discuss the role of information and communication in mental
health organizations and the importance of good communication to
Access to care is a fundamental principle of
both patient-centered care and psychiatric rehabilitation. Access
includes having care provided in clients’ communities, in locations
where clients feel comfortable, as well as care offered to clients in
their home environments. This could include care offered in a
shelter, in a neighborhood coffeehouse, or in a client’s house or
apartment. Access also includes the provision of care that is
affordable. Clients need to be able to afford premiums for health
insurance coverage as well as co-payments for services provided.
In Anthony et al.’s (2002) Principle 5, the importance of improved
outcomes in a variety of service areas and disciplines is
emphasized. Achieving improved residential, educational, and
vocational outcomes depends on access to appropriate and affordable
Emotional support to cope with fear and anxiety is
an important patient-centered care principle. Psychiatric
rehabilitation practitioners believe in the essential role of emotional
support in the health care process, particularly in mental health care,
where a person’s entire sense of reality can be undermined by his
symptoms (Sharfstein & Dickerson, 2006). The stigma
that still exists toward individuals with mental illness is another
reason why emotional support is so critical (Corrigan, Watson, Byrne,
& Davis, 2005). Service users need to feel accepted and
welcomed at the places where they obtain services. Anthony et al.
(2002) further accentuate the need for hope among psychiatric
rehabilitation practitioners, which enhances emotional support for
Another principle of patient-centered care is
involvement of family and friends in the care process. This is
important in psychiatric rehabilitation, as well, as we enlist support
from people such as family, friends, and significant others who can
assist in the rehabilitation process. To the extent that the
service user desires such involvement, it is important to include
family and friends in treatment planning, goal setting, and
rehabilitation processes. Family and friends can help users to
determine goals for themselves, and they can also assist in advocating
for users’ needs and rights. Advocates from organizations such as
the National Alliance on Mental Illness and the Depression and Bipolar
Support Alliance continue to hold community mental health providers
accountable for involving support persons in treatment planning and
Physical comfort may not seem immediately
relevant to community mental health, but it is. In agency
settings such as waiting rooms, drop-in centers, and clinician offices,
an atmosphere of comfort and security is vitally important. In
addition, in its conceptualization of physical comfort, the Picker
Institute includes support for activities of daily living (Picker
Institute, 2010). Often, psychiatric rehabilitation practitioners
are involved in assisting service users with activities of daily living
and instrumental activities of daily living. Furthermore,
psychiatric rehabilitation providers play a role in helping users of
our services to obtain housing that is safe and comfortable.
Physical comfort can help service users to cope effectively with
sensory input and to feel secure in their environment.
and secure transition between settings applies to psychiatric
rehabilitation practice, as well. As service users make
transitions from inpatient psychiatric settings to the community, we
want to ensure that they obtain the support that they need.
Continuity between providers and clear directions on transferring care
from one setting to another can make the difference between stability
and chaos for a service user coming out of an acute care
facility. Community mental health users also frequently make
transitions to and from different kinds of housing arrangements, such
as going from assisted living to an independent apartment
setting. Assuring that service users are able to make these
transitions in a stable, healthful way is important to what we do.
managers at community-based mental health agencies do a great deal of
coordination and integration of care for service users. They
provide linkage of physical and mental health services, income and
housing support, and vocational and educational services. They
also provide support for dealing with paperwork associated with
different services and programs that people may use. Coordination
and integration of care is based on the user’s choice of
services. Without this coordination of care, many service users
would get lost in the system.
Application of Patient-Centered Care to Corrigan’s Model of Psychiatric Rehabilitation
does patient-centered care apply specifically to the theory underlying
psychiatric rehabilitation practice? An examination of
patient-centered care principles through the framework of Patrick
Corrigan’s (2003) model of psychiatric rehabilitation gives important
insights into this question.
Corrigan posits that psychiatric
rehabilitation involves four key structures: goals, strategies,
settings, and roles. The principles of patient-centered care can
be applied to each of these four structures.
rehabilitation supports users’ formulation of their own goals for the
rehabilitative process. Goals that are important to many
participants in psychiatric rehabilitation include independence in
daily living and inclusion in the life of the community in which the
client lives. Patient-centered care also involves respect for
users’ values, preferences, and expressed needs. In a
patient-centered care setting, goals of the treatment process are
determined by the desires of the service user, not the priorities of
the professional. Also, in emphasizing physical comfort,
patient-centered care supports safe, comfortable living environments,
just as psychiatric rehabilitation practitioners seek such environments
for those who use their services.
rehabilitation includes the strategies of goal assessment, skills
training and education, and provision of support. These
strategies are congruent with a patient-centered care
perspective. In patient-centered care, as in psychiatric
rehabilitation, users determine what is important to focus on in the
treatment process. Patient-centered care also involves provision
of information and education to people, to support their capacity to
make their own care decisions and to teach them skills for
self-management. In addition, patient-centered care supports
two-way communication between users and providers about the care
process. Provision of support—emotional and practical support—is
an invaluable strategy in both psychiatric rehabilitation practice and
rehabilitation is a method of mental health practice that can take
place in a wide variety of settings—especially outpatient,
community-based, and residential settings. The goals and tasks
associated with psychiatric rehabilitation are particularly portable
(Cnaan & Blankertz, 1990), in that goals can be assessed and skills
taught wherever people with mental illness may live, socialize, and
work. Likewise, though patient-centered care had its origins
largely in inpatient settings, the concepts and values of
patient-centered care have translated to outpatient, community clinic,
assisted-living, and rehabilitation settings.
main point about roles in psychiatric rehabilitation is that
practitioners’ roles are flexible and not strictly defined.
Physicians play a specific role in prescribing medicines, but other
providers on care teams may fulfill different roles at different
times. This can apply to the concept of patient-centered care, as
well, as attention to the needs and preferences of service users
requires flexibility in the provision of services.
do we meet the needs of the service user—give back control—when the
person is being treated involuntarily? Psychiatric rehabilitation
practice gives us some clues. In working with involuntary service
users, it is helpful to try to construct a “bridge” to the person by
acknowledging that the person did not choose to seek care, but also
attempting to determine what motivates him or her (Rooney, 2009).
There may be common themes that can unite the provider of mandated
treatment with the involuntary service user. People may recognize
that they need safety and stability in their lives, but may disagree
about how to achieve these goals. Providers may be able to
implement a dialogue with the person to determine what can be agreed
For example, patient-centered care works well
with a motivational interviewing approach, in which the service user’s
concerns and values drive the dialogue (Miller & Rollnick,
2002). Behavior change is supported by a focus on the factors
that matter most to the service user. Patient-centered care, with
its emphasis on respecting the person’s values, preferences, and
expressed needs, as well as shared decision-making, provides a useful
way to think about work with involuntary service users. This is
especially important in mental health settings, where people may find
themselves in treatment as a result of legal intervention designed to
protect their safety, but often experienced as intrusive. When we
can use the tenets of patient-centered care to seek common ground, we
make adherence more likely.
should learn from our colleagues in health care. They are
definitely on the right track, in terms of taking patients’ perceptions
of their care seriously and using assessment instruments that put the
well-being of patients first. We can take the principles of
patient-centered care and translate them into standards and
expectations that will enrich the quality of the care we provide and
truly put service users in the center of the care process.
addition, our colleagues in health care can learn from us. Our
growing orientation toward recovery-based services, as well as models
of shared decision-making and empowerment that have been pioneered by
psychiatric rehabilitation providers, serve as wonderful examples for
the rest of health care. As behavioral and physical health care
become more integrated, using common models to inform service delivery
and assessment of patient/client satisfaction will streamline care
processes and ensure that our service users’ preferences are valued and
Not only do we need to embrace principles of
patient-centered care in our service provision, but we need to be
creative in developing ways of measuring our success in achieving these
goals. The Picker Institute has demonstrated that asking health
care clients about their satisfaction with services does not provide
sufficient understanding of whether service users have truly
experienced health care tailored to their needs; it is also important
to ask about the occurrence of specific actions on the part of health
care providers (Picker Institute, 2010). In addition, psychiatric
rehabilitation clients must be involved in planning services and
determining criteria for their evaluation (Bechtel & Ness, 2010).
care has the potential to reduce health disparities, increase service
users’ role in decision-making, and improve health care processes and
outcomes (Epstein, Fiscella, Lesser, & Stange, 2010). In
general health care as well as in psychiatric rehabilitation practice,
we have a long way to go to achieve true empowerment among those who
use our services (Tomes, 2006). However, by applying principles
of patient-centered care to the practice of psychiatric rehabilitation,
it is possible to come a bit closer to the goal of providing equitable,
empowering services to people with mental illness.
for Healthcare Research and Quality (2009). National Healthcare
Quality Report, 2009. Retrieved April 29, 2010 from
W., Cohen, M., Farkas, M., & Gagne, C. (2002). Psychiatric
rehabilitation (2nd ed.). Boston: Center for Psychiatric
W. A., & Huckshorn, K. A. (2008). Principled leadership in
mental health systems and programs. Boston:
Center for Psychiatric Rehabilitation.
E. (1969). The possibilities of patient-centered medicine.
Journal of the Royal College of General Practitioners, 17, 269-276.
C., & Ness. D. L. (2010). If you build it, will they
come? Designing truly patient-centered health care. Health
Affairs, 29 (5), 914-920.
P. D., Edgman-Levitan, S., Roberts, M., Moloney, T. W., McMullen, W.,
Walker, J. D.,& Delbanco, T. L. (1991). Patients evaluate
their hospital care: A national survey.
Health Affairs, 10, 254-267.
R. A., & Blankertz, L. (1990). Experts’ assessment of
psychosocial rehabilitation principles. Psychosocial
Rehabilitation Journal, 13 (3), 59-74.
P. W. (2003). Towards an integrated, structural model of
psychiatric rehabilitation.Psychiatric Rehabilitation Journal, 26 (4),
W., Watson, A. C., Byrne, P., & Davis, K. E. (2005). Mental
illness stigma: Problem of public health or social
justice? Social Work, 50 (4), 363-368.
M., Edgman-Levitan, S., Daley, J., & Delbanco, T. (eds).
(1993). Through the patient’s eyes: Understanding and
promoting patient-centered care. San Francisco: Jossey-Bass.
of Medicine. Committee on Quality Health Care in America
(2001). Crossing the quality chasm: A new health
system for the 21st century. Washington, DC: Author
of Medicine. Committee on Crossing the Quality Chasm:
Adaptation to Mental Health and Addictive Disorders (2006).
Improving the quality of health care for mental and
substance-use disorders. Washington, DC: Author.
A., Gzil, F., Cammelli, M., Lefeve, C., Pachoud, B., & Ville, I.
(2007). Person-centredness: Conceptual and historical
perspectives. Disability and Rehabilitation, 29 (20-21),
J. H., McCracken, E. C., McWhinney, I. R., Stewart, M. A. & Brown,
J. B. (1986). The patient-centred clinical method.
1. A model for the doctor-patient interaction in family
medicine. Family Practice, 3 (1), 24-30.
W. R., & Rollnick, S. (2002). Motivational
interviewing: Preparing people for change. (2nd ed.). New
York: Guilford Press.
Institute. (2010). Welcome to Picker Institute.
Retrieved May 5, 2010
H. A., Page, A.E.K., Druss, B., Appelbaum, P. S., Gottlieb, G., &
England, M. J. (2007). Can psychiatry cross the quality
chasm? Improving the quality of health care for mental and
substance use conditions. American Journal of Psychiatry, 164
G. (2009). Oppression and involuntary clients. In Rooney,
R. H. (ed.). Strategies for work with involuntary clients
(2nd ed.) . New York: Columbia University Press.
S., & Dickerson, F., (2006). Psychiatry and the consumer
movement. Health Affairs, 25 (3), 734-736.
N. (2010). The patient as a policy factor: A historical
case study of the consumer/survivor movement in mental
health. Health Affairs, 25 (3), 720-729.