This study explores the meaning of the use of community psychiatric rehabilitation (CPR) services to gain knowledge to improve services and shed more light on how to facilitate recovery. The topics explored included: the motivation for participation, perception and expectation towards CPR, the interactions with professionals in the CPR Center, and the feelings towards activities. A qualitative approach was adopted, and 30 consumers were interviewed face-to-face by using semi-structured interview guide. Data were analyzed using the open coding method of grounded theory. The consumer accounts provided information on the eight aspects of CPR services. The findings revealed that the CPR Center created a lifeworld, a friendly place similar to home with structure and activities. Professional relationship was the key change agent for rehabilitation. Most professionals adopted recovery-oriented approach to empower participants by giving opportunities and choices. The essential ingredients of this lifeworld covered rehabilitation goals, physical exercises, psychological impact, social interactions, learning, and economic gains. The services were venues for interpersonal interactions and provided structure for daily life, which helped consumers reach their rehabilitation goals and brought existential meaning to their lives. Yet, the accounts also revealed negative phenomena in the CPR center. Suggestions were made to improve services.
Mental disorders have been a common problem globally. In 2019, 1 in every 8 people, or 970 million people around the world were suffering from a mental disorder, with anxiety and depressive disorders the most common [
Mental disorders could cause a tremendous personal and socioeconomic burden. On the socioeconomic level, two of the most common mental health conditions, depression and anxiety, cost the global economy US$ 1 trillion each year [
Despite the essential role of CPR for recovery, Rössler [
According to the Oxford dictionary, the definition of meaning includes: “the real importance of a feeling or an experience” and “a sense of purpose”. The Webster dictionary described meaning as “something meant or intended” and “implication of a hidden or special significance”. Thus, “meaning” may refer to the motivation and purpose (goal) to use CPR with the important components on CPR from the consumer perspective and the feelings they derived from these services.
Ramafikeng et al. [
The literature has revealed that there are some essential ingredients for meaningful CPR. Concerning the motive for participation, the need for socialization, and structured time use was the key motivating factors [
The quality of the professional relationship is a key factor for positive rehabilitation processes and outcomes. Krupa et al. [
Having a meaningful everyday activity and feeling productive have been repeatedly shown to be essential for recovery and enhance the perception of meaning in the consumers’ life. The day centers provide opportunities to earn money and learn new things [
In sum, the synthesis of existing literature has revealed that there are some essential ingredients for CPR to provide positive outcomes, including the motivation for rehabilitation, the quality of professional relationships, the need for socialization and structured time use, a sense of being part of a community, self-understanding, gaining new perspectives, adjusting to community life, the importance of participation, learning new skills, and participating in meaningful activities.
In Taiwan, the Ministry of Health launched CPR policy and services in 1985. They defined CPR services to include halfway houses, shelter workshops, community rehabilitation centers, and home care [
This study was the second part of a two-year study (from 2015–2017) on the community psychiatric rehabilitation model in Taiwan. The investigator adopted a qualitative approach to capture the comprehensive experiences and reach a deep understanding as to the feelings and interpretations of consumer [
The community rehabilitation center in Taiwan is a facility that is like outpatient treatment in the United States. The center provides case management services, social and recreational activities, occupational therapy, vocational training, and sheltered workshops. Based on the information provided by the Ministry of Health and Welfare in Taiwan, there were 44 CPR centers in the community run by a small nonprofit organization or an association. Of the 44 centers, 32 agreed to collaborate with the investigators. More detailed information concerning the recruiting of participating agencies has been published in another article.
Participants were recruited from community psychiatric rehabilitation centers in Taiwan. Purposeful sampling was utilized and the criteria for the selection of participants were as follows: 1) consumers must have a severe mental illness (SMI) other than substance abuse, personality disorder, or dementia due to any cause; 2) consumers must have been hospitalized at least once since the onset of mental illness to further ensure they did have an SMI; 3) consumers must have used the services at the center for at least three months; and 4) they agreed to participate in the study. The selection of interviewees was based on the consideration of willingness, diversity, and conceptual saturation, meaning that the data could reflect the comprehensiveness of the experiences concerning the utilization of CPR services. Each agency was asked to recommend potential interviewees.
Research assistants conducted all face-to-face interviews with the interview occurring at the agency during the day. The participant’s case managers introduced the research assistants to the participants to help establish trust with them. The assistants all had been equipped with the knowledge on qualitative research approach through the courses at the university and the training sessions. A training session was conducted by the investigator to familiarize the assistants with the interview guide. Each interview lasted from 31–72 min and was recorded using both a tape recorder and a cell phone. Each participant was given a voucher (worth USD 16.67) for a convenience store as payment for participation.
An interview guide was designed by the investigator. It was finalized through a test interview and discussions with colleagues and the participating agencies. The participants were asked the following questions: 1. What makes you come to this agency? 2. What did you know about the agency before you join it? 3. What do you expect to gain from the rehabilitation? 4. How do you think of the professionals in the agency? 5. How do you describe your relationship with professionals here? 6. Please select the main professional who is important to you and describe your feelings towards him/her; 7. What impressed you most when you interacted with this professional? 8. What are the main activities you participate in? and 9. How do you think of the activities?
Grounded theory was adopted to process the data. It is “a qualitative research method that uses a systematic set of procedures to develop an inductively derived theory about a phenomenon” [
The script of each interview was transcribed verbatim into dialogic text. The procedure of data analysis began with open coding and conceptual labeling based on the grounded theory [
To establish the trustworthiness of the analysis, some feasible activities were conducted based on the suggestions of Lincoln et al. [
As a result, 30 consumers were willing to be interviewed. The in-depth interviews generated rich accounts from the participants. Eight aspects relevant to meaning are depicted in this section: the motivation for participation in CPR, knowledge of the CPR center, rehabilitation goals, the views towards professionals, professional relationships, feelings towards professionals, main activities participated, and feelings towards these activities. The details are described as follows. Due to limited space, only a few narratives are presented for each theme.
There were six major reasons that the participants joined the CPR program. First, 22 participants were referred by professionals such as a psychiatrist, nurse, and social worker, as well as the personnel of other rehabilitation agencies or city government. Second, 13 participants participated in CPR because of family members’ expectations. The family hoped that the participants could find the center of their lives, find a job, or make an adjustment after being discharged from the hospital. Third, 8 participants came to the CPR center to find a place to be, seek support, and to avoid conflict with family members, loneliness, and boredom. Fourth, 4 participants used the services because of the introduction of ex co-workers or peers. Fifth, mental health conditions and family situations made 6 participants feel that they need to make changes or work more on self-improvement. They participated in the activities to prevent themselves from deterioration, join sheltered work to ease financial pressure, and find a place that is accepting. For example, C18–1 felt the deterioration of his/her psychiatric condition and decided to face it; C16–1 no longer needed to take care of his/her mother so she could start a new journey of her own. Sixth, 3 participants came to this particular center because it was close to their home.
‘I had psychiatric disabilities and had no job then. I stayed at home idled. My mom told me to join the (CPR) center and to give it a try.’ (C2-2-1)
‘There was no one else at home. I felt lonely. He referred me to join X (center). I feel very happy here.’ (C25-2-1)
There were four categories of understanding among participants about the CPR center before they received the services: an agency to help participants with community living, a placement like a day hospital or sheltered workplace, a vocational rehabilitation agency, and limited knowledge about the center. First, 6 participants understood that the CPR center provided services to help them with medication, remain stabilized, learn skills for daily living, and have a structured life. Second, 3 participants thought the CPR center was similar to a day hospital, a place for people with psychiatric disabilities, and a sheltered workplace where there was no pressure and less competition. Third, 7 participants focused on work and thought that the CPR center provided work opportunities, vocational training, and employment referrals. Fourth, 16 participants did not have a clear idea of what the CPR center was for before joining the program. Professionals or family members had not informed them of the purpose and content of the CPR services. C17 mentioned that he/she was worried that he/she might be deceived.
‘It is a place to provide persons with psychiatric disabilities with training for daily living.’ (C20-2-1)
‘This place is like the day hospital I used to go. You would have a normal life there. They told me that here is simpler than the day hospital, so here I am.’ (C31-2-1)
The participant rehabilitation goals included five domains: health, ego function, community life, employment, and interpersonal relationship (
Domain | Content | |
---|---|---|
Intrapersonal level | Health | Symptom stable & health promotion |
Ego function | Self-efficacy & self-integration | |
Interpersonal level | Community life | Anchored life, back to the community, independent life, & caregiver burden lessened |
Employment | Training & potential development | |
Interpersonal relationship | Interaction, support, & companionship |
‘I expect that I could regain normalcy, even better than I used to be. Because I remember even when I was normal…I felt so painful inside of my heart…I hope this time I can make a good adjustment, have a good rest, and resolve the pain.’ (C16-2-3)
‘I expect myself to keep up with the outside world… What I expect is that I can live a life with dignity.’ (C18-1-3)
The other three domains were related to interpersonal goals. First, 11 participants focused on enriching community life. They mentioned that through CPR they could gain the center of their lives and have social interactions, learn new things, and enrich their lives. In addition, they wanted to learn practical skills so that they could live independently and lessen the burden on their caregivers. Second, 21 participants had employment-related goals. They wanted to have some earning through shelter work in the center. Through vocational training, they would like to have a better job or competitive job. Some hoped to reach financial independence. Third, 11 participants emphasized interpersonal relationships. CPR centers provided them the opportunity to interact with other people. They wanted to improve interaction skills, make new friends, have fun with peers, gain support, and, hopefully, have an intimate relationship.
‘The reason that I come here is hoping that I can have a place to learn things. Because you won’t feel bored when you are learning, and you will feel happy.’ (C20-1-6)
Most participants held positive views towards professionals at the CPR center in two domains: recognizing professionals’ effort and professionals assisting participants on rehabilitation. First, 25 participants expressed positive comments on professionals about their work attitude, ethics, and professional skills. They mentioned that professionals are good listeners, with various professional skills, and provide accessible services, work hard, are patient, capable, and emotionally steady, actively planning for them and having a good working attitude, being a person with integrity, and acting as a role model. Additionally, professionals could appreciate participants’ strengths and provide adequate assistance. Professionals actively engaged with participants with a good attitude, which made participants feel close to professionals.
‘The workers here are very amiable. They need to be very patient so they can work with people like us. I think that they did it with love. They actively design activities for us.’ (C2-1-2)
Second, 18 participants mentioned that professionals assisted participants on rehabilitation including helping them with community living, providing guidance to rehabilitation, and providing psychosocial education for caregivers. Professionals encouraged participants to participate in community activities, provided them suggestions on daily life problems, and assisted them in managing health and emotions, among others. Participants thought that professionals encouraged them to participate in various competitions, provided the training and work opportunities, guided them to think about what they wanted and how to get there, and helped them with a democratic approach and warm attitude.
‘Professionals could address my difficulties well. They provide the help that I need. They did not get away from the theme or handle it hastily.’ (C16-2-3)
‘They (professionals) won’t solve the problem for you. They guide you to think about it and then assist.’ (C15-1-1)
Yet, 6 participants mentioned the negative side of professionals. The complaints were related to professionals’ work attitude, approach, and skills. C6 thought that professionals’ kind attitude could not push him/her to change. C18 commented on the turnover of the workers in the center. New workers were not as helpful as more experienced ones. He/she thought that the most important ability was to understand participants not just using theory. C19 mentioned that professionals did not handle well the troublemakers in the center.
‘It is useless. He/she still comes to the center…The worker should call his/her parents. He/she shouldn’t behave this way, coming and going as he/she wishes, throwing things at people… It is so scary!’ (C19-2-7)
Some felt that professionals were too busy to interact with participants.
‘The workers are so busy… If participants were not aware that workers were busy and went to talk to them, then workers would be very unhappy. So, participants usually don’t talk to workers much.’ (C31-2-15)
Participant accounts revealed four types of professional relationships: as a family member, like a friend, like a friend and a teacher, and just a professional. First, 6 participants thought that professionals were like family members to them. Professionals understood them, even better than their true family members.
‘I think that they (professionals) understand me more than my family members. They know how to get along with me… My family members are good to me, too, but they don’t know how to treat me… They know how to treat us…. They are more patient. We have less chance to be hurt by their words.’ (C2-1-3).
However, just like family members, they expressed true feelings to each other, which might create conflicts. Second, 15 participants thought professionals were like friends or peers to them. They had fun together, shared information and experiences, and treated each other for food, etc. Professionals interacted with participants in a natural way. Just like C20–2 said: ‘We are like friends, equal…. When I have some wrong ideas, thoughts, or doubts, I’ll ask them. They would give me useful advice.’ Third, 3 participants thought that professionals were like a friend and a teacher. Sometimes, professionals acted as a friend. However, they have professional knowledge and play a coaching role. Participants usually treat professionals as ‘teachers’. Fourth, 12 participants viewed professionals as just a professional. Some did not ask for help from professionals for personal matters because they relied on their own religious beliefs to solve problems, or because they were shy. Some centers focused on vocational training; thus, the professionals acted more like managers. Some professionals also acted as a coach and guide for daily living, work, and problem-solving.
‘Our relationship is okay, but not like friends. We maintain a professional relationship. They care for us, and they are teachers, too. We are students who come here to learn. And I am also a patient.’ (C16-2-4)
Most participants held positive feelings towards professionals, including being valued by professionals and feeling happy during the interaction, acknowledging the helpfulness of professionals’ service, and interacting smoothly. First, 14 participants showed appreciation for professionals since they felt the warmth, kindness, and patience from them. They used to be the ones to be blamed, judged, or neglected by others. Nevertheless, they felt being valued and cared for attentively by professionals. Based on this good relationship, some participants felt it was enjoyable to be with professionals. Professionals were accessible and kind, which made participants feel included. Some felt that participants and professionals could interact on equal footing without pressure. They cherished so much the time they spent together. Second, 17 participants acknowledged the helpfulness of professional services in the following. Participants thought that the professional services were effective in several ways, such as medication, health behaviors, family communication, self-reflection, problem-solving, emotional management, and stability to participate. Professionals facilitated consumer autonomy by assigning responsibility as a leader, offering opportunities for learning vocational skills, and coaching participants for independent living. Due to psychiatric disabilities, participants often experienced over-protection or deprivation of their right for making decisions. Thus, they felt quite impressed by the endowment of responsibility and opportunity offered by professionals. Some participants commented that professionals were competent with great credentials and could empathize with the hardship of the professionals’ work. Participants mentioned that professionals provided them with food, drink, cash, or voucher, among others as a reward for positive behaviors or achievements. Third, 6 participants felt that they had a close relationship with professionals. They could disclose their inner feelings even dreams with professionals. They chatted and made jokes with each other. Furthermore, the enjoyment could turn into a romantic fantasy toward a particular professional, such as C6–1.
‘I think that workers are all very amiable. They helped us solve all the problems. And they work so hard, which made me feel being valued.’ (C15-1-3)
‘(I was assigned) the role as the foreman…. I like it. Being a foreman, I should work fast, cannot be slow.’ (C19-1-11)
Nevertheless, 6 participants had negative feelings towards particular professionals as well. Professional’s authoritative or emotional behaviors, such as being angry or accusative, would distance participants from them. In addition, some participants (C19–2 & C20–1) did not like to be asked about or to talk about personal matters. They could not be candid on these issues. Before the trust relationship is built, consumers could be afraid of the professional.
‘When I just came here, I was afraid of offending him (smile) and afraid of offending others. I was not that familiar with him. I just came here then.’ (C16-1-8)
Participants mainly participated in three major types of activities: physical activities, vocational rehabilitation, and community participation. Various physical exercises were taking place in the agencies, such as football, basketball, yoga, walking, or physical stretching, among others. Eight participants felt that they benefited from these physical activities. C15–1 mentioned he/she enjoyed doing exercises with peers. He/she said: ‘I met many classmates here. We do exercises together. I am very happy to share my exercise experiences with them.’ (C15-1-4). The second type was comprised of three categories of activities: vocational training (16 participants mentioned it), social and occupational training group (20 participants), and administrative tasks (4 participants). First, the vocational training in Taiwan is for participants to learn work skills in various fields, such as baking, cleaning, handcrafts, farming, or accounting, among others. Participants do small jobs and earn a salary. They could choose which type of work they like to participate in. Those with better performance were assigned the role of a foreman. Some might join the working group in the community later. Second, the social and occupational training group enhanced participants’ functioning in daily life. The activities covered cooking, painting, gardening, handcraft, and psychosocial education, etc. The social part focused on emotional management and interpersonal social skill courses. Third, some participants played the role of helping the operation of the agency, such as checking on the equipment, assigning work, or monitoring the work operation, among others. They usually were the ones with better functionality. Their participation could also further enhance their attention level.
‘I play a role in the self-governing committee. There are others on the committee. Before the committee is formed, I did most work. After the committee is formed, we share the work. If we run into problems, we go to XX (a professional) for help.’ (C18-1-7)
There were two types of community participation: outdoor activities (10 participants mentioned) and recreational activities (6 participants). First, most agencies facilitated participants to mingle with the outside world through participating in group competitions (such as sports, choir, or dancing, among activities), one-day or half-day trips, mountain climbing, etc. Most participants enjoyed this type of activity. C15–2 mentioned that: ‘We planned a half-day trip by ourselves. We decided where we wanted to go, how to get there, how much money we needed.’ (C15-2-3). Some agencies arranged participants to do voluntary work, such as cleaning a park. Second, participants would get together and do leisure activities, such as playing chess, doing handcraft, painting, shopping, or chatting. They are for relaxation and elevating interpersonal interactions and the quality of life.
Participants had both positive and negative feelings toward the activities they participated in. The positive feelings were related to the rapport built up among participants, increases in income, enhanced physical and mental health, enhanced confidence, had a good atmosphere that was inclusive, and they acquired information. First, 11 participants mentioned that they enjoyed the interactions with peers. They experienced the peace of mind, found peers who shared the same interest, gained friendship, and helped each other. The help from peers helped the rehabilitation process. Second, 7 participants mentioned that through doing shelter work or attending vocational training that they could earn some money and buy the things they need. That is important, as C26–1 said: ‘Spent my own money.’ C31–2 said: ‘Let others have a chance to recognize our products and make some money.’ Third, 12 participants felt that the activities helped maintain and enhance their health and function. Some felt that the activities made them find a center and their lives become more fulfilling. As C15–1 said: ‘In here I practiced the teaching of Buddhism, such as not being angry with others, being forgiving.’ Fourth, 12 participants mentioned that they received positive feedback and acquired confidence in doing these activities. They learned new things through trial and error but gradually gained proficiency. They also experienced growth, as C18–1 said: ‘I trust myself and others more…. Just do it and you will see the difference in yourself…’ Fifth, 16 participants praised the activities. They thought the activities are interesting, flexible, inclusive, exciting, and meaningful. They enjoyed the classes immensely. They also felt being respected and trusted by the professionals. C31 felt that the rehabilitation center is indispensable to him. The activities keep him/her from being over-focused on themselves. C2–1 mentioned: ‘I love to come here. I don’t like a holiday.’ Sixth, 6 participants mentioned that they were happy to learn new things. These activities are useful and practical in daily living.
Some participants expressed negative feelings toward the activities. The reasons included activities not interesting, unsatisfied with peer interactions, or the pressure from vocational training. First, 5 participants mentioned that part of the activities were not interesting or dull. For example, C4–2 said he/she does not like static activities. Second, 5 participants’ negative feelings stemmed from problems with peer interactions, such as boundary issues, interruption of other peers during class, or peers being passive or not emotionally stable. These problems had deterred participants’ willingness to come to the center. Third, 4 participants expressed the pressure from vocational training. Long working hours, low salary, and heavy workload resulted in physical fatigue, negative emotions, and limited time left for other things.
The accounts of the participants revealed that the CPR center created a lifeworld where for some participants it was like a home, for some it was a place to interact with people and make friends, for some it was a place for learning, and for some, it was a place for working and making money. In the lifeworld, participants found a center of their life through the structure of daily operation and the activities arranged by the CPR center (
Despite that most consumers expressed positive experiences with the rehabilitation center, some consumers revealed the negative phenomenon of this lifeworld (the gray area in
This study interviewed 30 consumers based on informed consent. In addition, the interviews were conducted in a counseling room of the CPR center. Although consumers would feel more comfortable in a familiar environment, the topics concerning the views and feelings on professionals and activities might induce social desirability and compromise the credibility and dependability of the accounts. The selection of the participants considered the diversity and narratives from the consumers provided rich information. Nevertheless, conceptual saturation could not be fully assured. Finally, despite that the participants had all came from 32 CPR centers in Taiwan and the investigator had provided the detailed content of the findings, the transferability is uncertain. Future studies are needed to further explore this subject.
This study portrays the lifeworld of the consumers at the CPR centers and the meaning derived from that. It is the first study of its kind in Taiwan. The accounts of consumers provided rich information on eight aspects that could shed further light on how to facilitate recovery. The CPR center is a place that is friendly even like a home. The services were venues for interpersonal interactions and provided the structure of daily life, which brought existential meaning to consumers and helped them move towards recovery.