From Relationship to Retention: Promoting Equity and Participation In Psychiatric Rehabilitation

Background and purpose

People coping with severe mental illness (SMI) often experience functional impairment, reduced quality of life (QOL), and limited community integration. Although psychiatric rehabilitation services (PRS) help address these challenges, many eligible either do not use or retain them, limiting their rehabilitation outcomes. This gap reflects not only unmet service needs, but also broader issues of equity, social inclusion, and community participation. In Israel, only about 30% of eligible individuals utilize PRS, and another 25%–30% use them only partially. While most studies have focused on PRS utilization, less attention has been given to retention, particularly the concurrent use of multiple services. Guided by Andersen’s Behavioral Model of Health Service Use (1995), this study examined the contribution of predisposing factors (age, gender, education, and religious affiliation), enabling factors (patient–provider recovery-promoting relationship [RPR] and family support), and need factors (psychiatric symptoms) to two outcomes: retention in PRS and number of services used. In addition, number of services was examined as a mediating variable linking patient–provider RPR to retention.

Methods

176 individuals with SMI entitled to Israeli PRS completed a self-administered online questionnaire distributed via social media and PRS organizations. Measures included retention in PRS (up to 1 month,2–3 months,4–6 months,7–12 months, and over a year) and number of services used (1–8) as dependent variables, alongside age, gender, education, religious affiliation, patient–provider RPR, family support, and psychiatric symptoms as independent variables. Hierarchical regressions examined predictors of retention and number of services used, and a mediation model tested the indirect effect of RPR on retention through service use.

Results

Retention was predicted by older age (β=.24, p=.002), more positive patient–provider RPR (β=.21, p=.009), and lower psychiatric symptoms (β=−.17, p=.043). Number of services used was predicted by patient–provider RPR (β=.27, p< .001), religiosity (β=.19, p=.010), and younger age (β =−.16 ,p=.048). Mediation analysis indicated that number of services used fully mediated the association between patient–provider RPR and retention (B=.33,95% CI[.18, .50]).

Conclusions and implications

The findings indicate that a more positive provider RPR contributes to retention mainly by promoting simultaneous engagement in multiple PRS, such as housing, employment, mentoring, and leisure supports. This highlights the number of services used as a key factor in retention and suggests that concurrent use of multiple services may be more beneficial than relying on a single service. Accordingly, professionals should consider offering combinations of PRS based on service users’ needs and preferences. At the system level, these findings underscore the importance of developing funding mechanisms that support the use of multiple services according to individual needs, while also strengthening coordination among services. In addition, older age was associated with higher retention, pointing to the need for age-adapted services for younger users, while the negative association between psychiatric symptoms and retention highlights the importance of staff training and service coordination for early identification of prevention of disengagement. Overall, these findings suggest that retention depends mostly on the system’s ability to provide broad, flexible, and tailored care