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by William D. Spaulding, Mary E. Sullivan, and Jeffrey S. Poland
Guilford Press, 2003
Review by Roy Sugarman, Ph.D. on Aug 3rd 2004

Treatment and Rehabilitation of Severe Mental Illness

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statement, they note that what is not new is well supported by a scientific evidence base, but what is new is largely unpublished, even though it follows an integrated perspective and presents new treatment approaches that draw on evidence bases in science anyway.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