Often in treatment paradigms, what is new doesn’t
work, and what works, is not new.  This is part of the dilemma in presenting an
integrated approach to the treatment, or the rehabilitation of severe
psychiatric conditions.  The authors here have backgrounds in psychology and
social work, and hold prestigious titles in universities.  With regard to my
opening statement, they note that what is not new is well supported by a
scientific evidence base, but what is new is largely unpublished, even though
it follows an integrated perspective and presents new treatment approaches that
draw on evidence bases in science anyway. I’ll let the authors explain:

Our position is a pragmatic one. 
Clinicians, academicians, advocates, and consumers who understand
rehabilitation in a broad and conceptually coherent framework are expected to
be more effective than those who are familiar with various technologies or
principles but who do not systematically engage these elements in an integrated
approach.  Similarly, individual whose awareness is limited to particular
technical elements within the rehabilitation armamentarium€¦..are not expected
to incorporate, in their daily practice, the social values and ethical
principles that help define the rehabilitation enterprise.  This book aspires
to demonstrate the viability and accessibility of a broad, conceptually
coherent, ethical, and clinically useful conceptual framework for
rehabilitation (page viii).

And indeed it does.

The authors note that despite
advances in technology, little has been brought to patient care in terms of
different approaches and better outcomes.

I work in such an area, which has
brought a host of paperwork to define outcomes without the slightest gain in
the quality of face-to-face contact, but boy, do we look good! The drug
companies of course have followed the medical model to the full, developing the
vast range of serotonin-dopamine affinity drugs, with some gains, especially in
the negative symptom cluster, worsened by the older drugs, but overall patients
with severe mental illness have remained unwell.  Un-well refers, in the recovery
model anyway, to the paucity of restoration to full social standing and
status.  In other words, when you get un-well, you lose your place in the queue
for the joys of life, fall off your rung of the psychosocial ladder, and land
in the dirt, where you then wallow.

The reasons so often given relate
to the non-integrated medical model, namely a disease theory of mental
illness.  Not wrong in and of it’s self, this model implies a linear cause and
effect causality, which holds that the reversal of the process will be
curative. Namely, mental illness is caused in a linear fashion by a
neurotransmitter problem/lack or something, and hence giving more or less,
sometimes in different locations, will right the seesaw balance (teeter-totter)
in the right direction.  Of course, from Pilowski in the UK and Kaipur in Canada,
and others, we now know that flooding D2 receptors doesn’t necessarily
eliminate psychosis, nor does flooding 5HT2a in the cortex, but a nice balance
between the two, such as exemplified in clozapine, does the trick, k-off times
and all. Newer ‘Goldilocks’ drugs (to quote Steve Stahl) attempt to address the
circularity of second order cybernetic circuits in the brain by titrating this
effect. 

In order to address this, the
authors have called on a biosystemic model to deal with a more circular cause
and effect paradigm, citing von Bertalanffy and general systems theory to deal
with these issues.  They develop a much more circular argument, which brings in
the perturbations that the client might receive from other effects in the path
to illness.  Beginning in Lincoln Nebraska in 1982, this evolved into an 11-step
plan, beginning with a mission statement. 

The circularity of
cause-effect-cause feedback does not however address the issues germane to
rehabilitation and recovery: mental illness results in disability and a loss of
social capital, and this has to be addressed beyond the symptom load.  As the
authors note, scientific advances become clinical tools as their relevance to
real human problems becomes understood, confounded by the heterogeneity of the
affected population, and the polymorphic nature of the illnesses.

This alone discourages the idea of
cultural universals or universal one-size-fits all paradigms in existing care
facilities, and reflects on the ambiguity of our clients’, and our own, often
un-testable hypotheses about what constitutes mental illness, leading to
pseudo-science and lack of consensus.  Mental health services without a
grounded underpinning (hence the 11 step model beginning with the mission
statement), fall foul of politics and internecine warfare, with a war cry so
often used by one on the other, ‘semantics and philosophy!’  Kuhn of course
pointed out that societies cling to old paradigms, and resist alternative new
paradigms.

One of my professorial colleagues
made this all too plain to me recently.  Faced with a challenge to his single,
dominant paradigm (which supported psychiatry as a greater force than
psychology in treatment) he noted that my approach, while "cutting
edge", ran counter to the "way we have done things around her for 30
years, and our way has always worked".  The trick of course was that the
outcomes he referred to, namely getting patients out of asylum care, was valid
in the 50’s, but not so valid now: my outcome measures are different. 

What was depressing was the fact
that this comment in 2001 was exactly equivalent to that from my professor in
psychiatry in 1991, ten years before on another continent.  Kuhn indeed. 
Dominant paradigms rule, for a long time. Despite "creaking under the
weight of discomfirmatory data and practical limitations" (page 7) such
arcane and archaic fantasies about what constitutes mental illness and how to
treat it, live on in the Kuhnian sense.

The early chapters here are thus
vital, and lead on to the rest of the book, and let you know that you are
facing heavyweight principles in this work, not semantics or philosophy, if
this is Ms Universe, it is beauty with a purpose.  11 Pages in, and I am
impressed.

Unfortunately, as the authors note,
there will be no dramatic Kuhnian revolution, with consumers taking to the
barricades, joined by hoards of HMO’s: but there is pressure to change.  Again,
vague underlying epistemologies, or especially vague ontologies, are as difficult
to disprove as they are to prove€¦..

The Psychopathology of Severe
Mental Illness chapter carries on in the same vein, moving predictably, and
correctly in my view, to an elaboration of the human psychological system as a
self regulating biosystem, with reference to functional homeostasis, and the
excellent caveat against isolating the internal semi-open semi-closed human
system from its ecosystem, ranging across the molar to the molecular. 
Certainly, this raises the question of causality, and the authors deal with
this as well in this chapter.  They refer to ‘biosystemic analysis’, a term I
like, given my ecosystemic training in General Systems Theory.  Readers who are
caught up by this kind of discussion would do well to read Gregory Bateson
(Margaret Mead’s husband) and his views on mind and brain, as well as Paul
Dell, Maturana and Varella, and other systemic thinkers besides von Bertalanffy,
whom they cite.  Bateson asked "Why do things get in a muddle"
drawing on the earlier work of Wittgenstein, Russell and Whitehead, and later
on, Watzlawick, Weakland and Fisch in communications theory within a general
systems approach.

It is against this wealth of post
modernist thought that the authors have developed their 11 part, thematic based
approach, not philosophy and semantics, as one of my colleagues recently
sneered, but heuristically useful epistemological concerns which define our
ontology, our view of what we regard as facts about psychopathology.

This then informs on The Structure
of Clinical Assessment, Formulation, and Rehabilitation Planning covered in the
next chapter.  Predictably, given the neurepistemology above, this process is
again not linear, but recursive and self-regulatory.  Assessment and
rehabilitation planning are seen as unifying processes intended to bring
together the perspectives of the recovering person and the various other
members of the treating or rehabilitation team in a multidisciplinary
homeostasis-engendering biosphere (whew!!). Okay, a multi-D team that works
dynamically, okay?  Good.

This is of course not family
therapy or systemic a view, but owned by the entire schools of therapeutic
delivery of services.  Several references for this are given. The salience of
the clients view is respected, as behooves a recovery-based philosophy, in
accordance with the vision of Anthony and others.  Tied to this are the more
concrete outcomes of measurable goals, much beloved of the Barbara Wilson style
of rehabilitation in traumatic brain injury, a very pragmatic approach to rehab
as it is, and as it could be, a problem-centered approach to disability
management.

Part II of the book changes gears,
and moves upward and onward into the neuro-physiological aspects of neurobehavioral
presentations from its historical base in the 1930’s, coinciding with
Wittgenstein and Russell-Whitehead evolutions.  Consequently the value of
considering neuro-physiological dysregulation exams distinct subsystems,
appreciating that there are different levels of abstraction, even though they are
referred to here as rhetorical: I do not believe they are. There is some really
linear thinking here, but language after all is linear, and hard to use to
explain complex biofeedback loops on different levels, without epistemological
error in the Bateson sense. Wow.  There is later on an appreciation of the
polymorphic and idiosyncratic presentations possible, but various forms of dysregulation
are also discussed in an attempt to bring order to chaos.  The authors do not
get into entropy and enthalpy here, but these concepts cannot be far behind.

Chapter 5 is devoted to neuro-cognitive
functioning, and again uses heuristic devices to bring some structure to the
concepts that would enable superordinate dimensions with which to organize
their approach to rehabilitation.  Spaulding reverts to an earlier formulation,
basing their work on a three-factor model, namely baseline functioning,
episode-linked impairment, and post-acute functioning.  In my reports, this
would be who were they? What happened to them? Who are they now?  These are of
course "sources of variance" rather than typologies or categories. 
It also is a powerful tool that demonstrates how clients within a specific
category differ from one another, and this allows for client based, individual
programs with individual goal-setting within rehabilitation.  It’s a nice,
tight chapter that follows with instructions for assessment around the
three-factor model of cognitive dysregulation.

Chapter 6 focuses on mechanism of
cognitive recovery, and again you can see how the language is on recovery, not
repair or rehabilitation.  Structure and function are separated out, with three
viable hypotheses identified. One, new skills are learned, two, lingering
disability is the result of functional hiatus, not structural change, and
three, microstructural instabilities can stabilize during person-environment
interactions (is this a cop out?).  There is therefore the implication that
interactions between person and environment, system-system-within-ecosystem
interactions, can bring about changes in brain organization. A massive argument
about function vs structure, skill acquisition vs. functional change, etc,
occupies barely one page (124-125) and this little aside could fill one of Gazzaniga’s
volumes if expiated!

The book settles into its stride,
with chapters on neurocognitive interventions, with the section on prosthetic neurocognitive
interventions particularly interesting, into chapter 8 which moves from the
individual to social-cognitive processes in research and treatment:

There is less isomorphism between
social-cognitive constructs and their neural underpinnings, compared to neurocognitive
(or neuropsychological) constructs and their neural underpinnings.  This is not
a scientific weakness, although it is often mistaken for one by those who
indulge in a naïve reductionistic understanding of behaviour (page 157).

I really think these authors HAVE to have met my colleagues:
alternatively, I wish I had said that.

Finally the mission statement for Lincoln
evolved:

To provide state of the art
treatment and rehabilitation to individuals with severe and disabling mental
illness who cannot be safely or effectively served in any less restrictive
setting anywhere in the mental health system, and to help those individuals achieve
a stable adjustment and decent quality of life in the community (page 281).

Had my first cousin been there, she
would still be alive. And from there the rest of the 11 key characteristics of
their service programs are elucidated on: defining a recipient population, the
role of the program director, writing the procedures manual, sourcing
professional resources, as well as para-professionals, clerical and support
staff, training all of them, managing the clinical data, controlling the
quality, developing the program, and the superordinate administrative support.

This is a most informative and well
thought through book, commending the authors on their 20-year task is
meaningless, they have clearly a job worth doing well, and they have done it
well.

It’s essential reading for anyone
in the helping profession, a most disabling field, and is a wealth of
definitive information for us all.

 

 

 

© 2004
Roy Sugarman

 

Roy
Sugarman PhD, Clinical Director: Clinical Therapies Programme, Principal
Psychologist: South West Sydney Area Health Service, Conjoint Senior Lecturer
in Psychiatry, University of New
South Wales, Australia

Categories: General, MentalHealth