Original Paper
Psychopathology 1992:25:139-146
J.P. Dauwaldera H. Hoffmannb Department of Psychology, U niversity of Lausanne, Switzerland; Social Psychiatry Clinic. U niversity of Berne, Switzerland
Chronic Psychoses and Rehabilitation: An Ecological Perspective
Introduction
In a historical perspective one might dis tinguish three major paradigms which charac terize the evolution of thinking in psychopa thology. The traditional paradigm, prevailing
Paper presented at the WPA Regional Symposium: Changing Psychiatry in Changing Societies. Budapest. August 23-25. 1991.
in the first generation, essentially aims at description and classification of psychopathological phenomena. While important ad vances, such as the now internationally ac cepted systems of classification (e.g ICD or DSM) were achieved, the practical relevance
Prof. Dr. J.? Dauwalder Department of Psychology University of Lausanne. BFSH 2 CH-1015 lausanne-Dorigny (Switzerland)
© 1992 S. Karger AG, Basel 0254-4962/92/ 0253-0139S2.75/0
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Abstract Traditional explanatory models, based on core psychological deficits, vulnerability-stress models or distinctions between negative and positive symptoms, may not be sufficient to understand the phenomenon of chronicity. This linear think ing. looking for monocausal explanations, should be replaced by exploring multicausal and circular processes over time, including the individual ecological context of a given patient. Thus, chronicity appears to result much more from endless loops and irreversible bifurcations in its dynamics over time than to be a stable state. Furthermore, the current views on psychopathology and prognosis need to be fundamentally reexamined in the light of this new way of thinking. For under standing and treatment of chronic psychoses, this ecological perspective implies programs which do not focus only on the patient, but look for 'ecological niches’ and interventions favoring synergetics and self-organization within the social networks and at the worksite of a given patient. A recently implemented five-step program for vocational rehabilitation and the corresponding research plan will be presented and dis cussed.
Individually Centered Approaches
A consistent description of specific behav iors that define chronic mental patients sel dom appears in the literature. Despite the convincing evidence of their poor overall so cial functioning, there exist surprisingly few data on the precise nature or the basis of their difficulties [2], In one of our former studies a complex pattern of social and situational vari ables (i.e. unremunerative occupation, un married state, lack of social contacts, higher age, pessimistic expectations but relative sat isfaction with the present situation) appeared to be much more characteristic of such pa tients than any diagnostic or psychopathologi cal variable [3], Similar psychosocial deficits in adapting to life in the community have also been described in subsequent reviews by Matson [4], Anthony and Jansen [5] or Wing [6], Traditional explanatory models, based on core psychological deficits [7], vulnerability-
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stress models [8, 9] or the distinction between negative and positive symptoms [10, 11] may not be sufficient to understand the phenome non of chronicity. More recently, the hypoth esis has been formulated that certain behav iors usually related to chronicity, such as emo tional withdrawal and reduction of initiative and interpersonal social involvement, could be understood as secondary coping strategies [12, 13], The suggestion of Rothbaum, et al. [14], that such a passive and withdrawn be havior may afford patients a certain sense of control (secondary control), might open ways for more convincing explanations of the spe cific behavior of these patients. Thus, rehabilitation can be directed to help chronic patients change inappropriate coping strategies. According to this view, rehabilita tion should enhance coping skills of the pa tient and reduce stressful influences from the environment. While evidence of the efficacy of specific training of social skills [15-17] and cognitive skills [18] exists, most of the inter vention studies have been performed in clini cal settings, where generalization to normal living conditions has been limited [2, 19], A major shortcoming of the approaches men tioned so far is the prevailing attribution of patients’ difficulties to themselves. While rehabilitaion programs intend to improve pa tients’ skills and abilities to fulfil social roles, they rarely explore the important obstacles and stressors present in the patients’ environ ment.
The Ecological Approach
In our opinion, linear thinking and monocausal explanations of chronicity based solely on patients’ characteristics should now be re placed by a more comprehensive and ecologi cal approach. By exploring multicausal and circular processes over time within the indi
Dauwalder/HolTmann
Chronic Psychoses and Rehabilitation: An Ecological Perspective
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of this approach remained unsatisfactory [1], The second paradigm, which still prevails ac tually, leads to the development of more gen eral explanatory concepts, such as vulnerabili ty-stress models, positive or negative symp tomatology or dynamics of structure. While practical relevance could be enhanced, these approaches mainly suffer from neglecting on going dynamics in the patient’s environment. In our contribution, we will focus on the emerging third paradigm, which tries to un derstand psychopathological phenomena as particular forms of underlying normal psy chological processes, such as coping, self-orga nization and synergetics in continuous adap tation of an individual person to her particu lar environment. More specifically, we will try to understand chronic mental disorders as a process rather than a psychopathological state.
A.H., a 48-ycar-old man. has been in psychiatric treatment since the age of 29. His clinical diagnosis is chronic schizophrenia (disorganized type). Even dur ing his premorbid young adulthood, communication difficulties at work were reported. During 7 years he worked at 5 different places. While living abroad for 2 years he lost contact with his family and former friends. Upon his return he decompensated rapidly and was hospitalized for the first time. Despite re peated efforts by several employers, he systematically lost every job during the next 15 years. The cause was always the same: feeling overwhelmed, he got tense and nervous and finally provoked arguments with his superiors. For 3 years he lived in a sheltered home, where he worked as a gardener. When he lost this shel tered workplace, he was referred to our industrial reha bilitation unit. Careful assessment of his instrumental abilities showed a performance level of about 50% of a normal worker. His main problems resulted from his social behavior with coworkers and superiors. Whereas so cial skills training proved inefficient, the patient was progressively integrated into our community-based ambulatory aftercare setting, which offers continuous case management by a treatment team. This setting provided a 'secondary' social network for him, through regular contacts with caregivers and former patients of the community. His slowly growing confidence in social relations was mainly reinforced by the availabil ity of a drop-in facility called the ‘round table’ [20]. After 10 months of vocational training in our rehabili tation unit, an appropriate ecological ‘niche’ for him in a print factory was found. At present, he continues working half-time, lives independently together with 2 other former patients and regularly visits our ambulatory' aftercare setting. In the print factory, he and his immediate superiors and coworkers get regular support and consultation from the case manager, which is very important for his maintaining his job.
The progressive social withdrawal of this patient, observed for years before his admis sion to our services, was not only due to his psychopathology or inappropriate behavior, but also to his lack of a supportive social net work and traditional ecobehavioral environ ment. His preferred problem-solving pattern resulted in an endless loop of unstable situa tions: whenever he got a job he lost it. A sim plified graphic summary of the ecobehavioral framework for describing the characteristic dynamics between approach (+) and avoid ance (-) interaction process during the prere habilitation phase is shown in figure la. There is now sufficient clinical and scien tific evidence that carefully orchestrated so cial support of the patient’s environment greatly enhances the effectiveness of rehabili tation programs [21-25]. Usually such inter vention programs focus upon the patient’s family. Our experience suggests the added benefits of including systematically all other significant persons (e.g. landlords or cowork ers) from the social network of a given pa tient. For many chronic patients there exists lit tle or no natural social network. In the case of our patient we therefore had to build up a ‘secondary’ social network in our ambulatory aftercare setting, in which the continuous treatment team facilitated communication and cooperation between all significant per sons and coordinated all therapeutic steps [26]. In our perspective this step was necessary to break the vicious cycle described above. The new dynamics created by this extended ecobehavioral environment proved to be stimulating. Though his deficiencies in social behavior could not be fully remediated, he gradually acquired more social and leisure activities as is depicted in figure 1b. The final step in vocational rehabilitation then was to find an ‘ecological niche’, where
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vidual ecological context of a given mentally ill person, rehabilitation will not only focus on a patient’s behavior, but consider his ecobehavioral environment, where chronicity is also maintained and reinforced by inappro priate coping strategies of significant others or adverse situational constraints. The following description of a typical case will illustrate our approach.
a
b
Pretreatment phase
C
Rehabilitation phase
Ecological niche P
N
N
W
Work dem ands more (+) Patient withdraws (-)
Social net supports work (+) Social net dem ands less (-) Work dem ands less (-) Patient approaches social net (+)
d
•
Endless loop
W
Social net supports work (+) Work supports social net (+) Work dem ands less (-) Patient approaches work (+)
f
Stable state
PNO
superiors and coworkers were willing to coop erate with the continuous treatment team which offered reliable support. As described in figure lc, the most important aim was to create a ‘dynamically stable state', despite the persisting deficiencies in social behavior of this patient. The graphic summaries of our treatment phases show that we explored multicausal and circular processes over time within the individual ecological context of this patient.
whether it will be on or off at the next moment - is governed by logical rules derived from the description of interactions in the first part. There result higher order regularities such as an endless loop in the pre treatment phase (d). an opening of possibilities with out stabilization in the rehabilitation phase (e) and a dynamically stable partial rehabilitation in the reinser tion phase (f).
In Search of a New Methodology
Beyond mere description, a more system atic and reliable methodology for the analysis of such ecobehavioral interactions over time has to be found. Traditional etiological mod els in psychiatry focus on genetic, anatomical, neurophysiological, personality or social vari ables. There exist few developmental models exploring temporal relationships and practi cally no ecological models exploring the re-
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Chronic Psychoses and Rehabilitation: An Ecological Perspective
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/
0 ONO
Fig. 1. Ecobehavioral dynamics between approach (+) and avoidance (-) interaction processes among patient’s behavior (P) and his social network (N) and work situation (W) for pretreatment (a), rehabilitation (b) and ecological reinsertion phases (c). By idealizing the behavior of each element as a simple binary (on or off) variable, there exist eight possible configurations. The dynamic behavior of each variable - that is.
I42
+
O PNW
OOO (
POO
»
ONW
OOW
POW
Opening
*
Social and vocational skills Symptoms and medication management
Social network Social support
Fig. 2. PASS - the system-related vocational reha bilitation program.
course, full rehabilitation success (PNW) might have been preferred. But for our pa tient. because of his lack of interpersonal skills, partial rehabilitation success was an op timal outcome. These new methods for analysis of the complex dynamics of ecobehavioral interac tions stimulate a number of clinically relevant questions: What maintains chronicity for a given patient? Where should our intervention be directed, in order to create new dynamics? What is the optimal rehabilitation success for a given patient? Can the clinicians’ intuition be replaced or completed by such dynamic models? Another shortcoming of usual voca tional rehabilitation becoming apparent from such analyses is the neglect of preparing and maintaining adequate ecological niches for chronic patients in their ‘natural’ environ ment. To transfer these theoretical ideas into practice we worked out an integrated voca tional rehabilitation program shortly de scribed in the following.
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sources or limits which influence the creation of adapted behavioral patterns through activ ity over time [27], Until now, dynamic pro cesses over time have been studied in psychia try at best with time series analysis or path analysis. In modern physics and chemistry, however, a completely new methodology for the study of complex dynamic systems over time has been developed. The findings of chaos theory [28], the work on dissipative structures by Nobel Prize winner Ilya Prigogine or on synergetics [29] are now widely known. In a series of recent investigations exploring their usefulness in the study of schizophrenia these methods have proved to be very promising [30], We used the simplest of these methods, called 'kinetic logic' [31]. The results of the analysis of the ecobehavioral dynamics for our patient across the subsequent treatment phases are summarized in figure ld-f. Given three conditions, being either present (P = adequate behavior of the patient. N = support from the social network: W = support at work) or absent (O = lack of one of these conditions), there exist eight possible configurations. The most probable transitions among these con figurations are shown for each phase. In the pretreatment phase an endless loop or vicious cycle excluding any of the configu rations involving support from the social net work was found. In the rehabilitation phase new configurations became accessible, how ever without stabilization in dynamics over time. In the phase of integration into the eco logical niche, a dynamically stable state (ONW) was found. Such a dynamically stable state results from dynamics over time and not from simple maintenance of a particular con figuration. It describes a homeostatic ecosys tem. In case of a relapse or perturbation, this ecosystem will rapidly restore this configura tion by its own dynamics. In other words, a ‘permanent’ rehabilitation is achieved. Of
The aim of this system-related program which we call PASS - is to achieve optimal vocational and social rehabilitation and to stabilize the chronic patient at a higher level of functioning [32], The P of the logo PASS means person, A stands for vocation (‘Arbeit’) and SS means social system. The complete program has five phases with contin uous ecobehavioral assessments. (1) The trial phase: The 2 weeks’ trial phase in our rehabilitation unit offers opportunities for the patient to become familiar with different fields and demands of work. During this time, the team gets a clinical grasp of the assets, resources and the deficits of the patient. Also the first assessment is performed in order to establish a baseline. (2) Rehabilitation unit phase: During a maximum of 6 months the patient next receives vocational train ing in our rehabilitation unit. During this period the first scries of social skills training is offered. Further more, psvchoeducational information on the nature of mental illness is given to relatives. They are invited to join a group of relatives for all subsequent phases. According to the clinical course and periodic ecobe havioral assessments, the ongoing programme is read justed. (3) Phase of training in enterprise: In order to reduce the ghetto-like situation of former rehabilita tion workplaces, we offer ‘natural’ training places, created in several businesses, trading and industrial companies. The places for training in enterprise are time-limited for each patient from 6 to a maximum of 18 months. For participating companies we offer a ser vice package, including psychoeducational meetings for coworkers and immediate superiors. Furthermore, our mobile rehabilitation team maintains case man agement. with 2 rehabilitation specialists regularly vis iting the companies and giving support to the patients and to the patients and to their superiors and cowork ers. During this phase the patients return twice a week to our unit for a second series of social skills training. If repeated efforts of problem-solving at the work site fail, we take the patient back into our unit. (4) Integration phase:' Lasting a maximum of 6 months, this phase is used for competitive job-finding. Similar to the company participating in the training
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enterprise, the definitive employer will be integrated in the rehabilitation process. (5) Aftercare phase: In the first month at a new job. but also later, psychosocial crises frequently occur. Superiors often show too much patience and effort keepi ng a patient, until they are exhausted and give up. The long-term case management by our mobile reha bilitation team offers crisis intervention aimed at pre venting the loss of the job.
Based on a critical evaluation of this com prehensive program we shall try to find some answers to more fundamental questions.
The Planned Research
Although most researchers recognize the need for multicausal, integrative and processoriented explanations of treatment and reha bilitation. there exists a lack of empirically founded models, especially for chronic men tal disorders. An empirical evaluation of the program, which is supported by the Swiss National Fund, will try to answer the follow ing questions: (1) Will exposure to a coherent set of inter ventions covering the ecological system of a patient lead to an increase and maintenance of his social and living skills, as compared to baseline functioning? (2) Will homeostasis-oriented, cyclical or change-oriented interactions among variables in the ecological system be found, and will these enable a better understanding of the rehabilitative process? (3) Will efficiency of rehabilitation be en hanced by targeted intervention strategies within the ecological system of a patient, if these are based on such process-oriented anal yses? The clinical studies will be centered on two consecutive series of prospective and con trolled multiple-baseline, single-case designs [33] followed each by detailed multidimen sional evaluations of outcome [34], This pro
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An Integrated Vocational Rehabilitation Program
cedure will permit adaptation of the treat ment program in the second series based on the previous experience, as well as multiple comparisons between the first and second se ries, based on time-series analyses [35] and new methodologies, such as the one presented here.
Conclusions
The search for a unique and simple cause for schizophrenia, also induced by the tradi tional paradigm of psychopathological think ing. has proved to be unproductive. If we con sider the now widely accepted need for multicausal, integrative and process-oriented ex planations. there exists a lack of empirically founded models, especially for chronic schizophrenia. To simulate concrete dynamic processes postulated by such models, we need more appropriate tools for quantitative analy
ses. In psychiatry, recent studies on dynamic modeling seem very promising. This applies particularly to studies on schizophrenia. As Strauss [39] pointed out, there exist at least three typical forms of evolution for chronic schizophrenia, which could be best under stood in such a dynamic perspective. Interestingly enough such a dynamic per spective was recently described for the initial phases of acute schizophrenia by Klosterkotter [40], Still more exciting are the very pre cise simulations of Schiepek and Schoppck [41 ], which prove that such an approach is not only feasible but that its outcomes are clini cally highly relevant. Thus we do not feel lonely in our approach, but rather excited about the promising and extremely rich new prospect which is opened before our eyes for a new and better under standing of this terrible condition called chronic schizophrenia.
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9 Spring B. Lemon M. Fergeson P: Vulnerabilities of schizophrenia: In formation-processing markers: in Straube ER. HahKveg K (eds): Schizophrenia. Concepts, Vulnera bility, and Intervention. Berlin, Springer. 1990. 10 Crow TJ: The two-svndrome con cept: Origins and current status. Schizophr Bull 1985:11:471-485. 11 Andrcasen NC: The diagnosis of schizophrenia. Schizophr Bull 1987; 13:9-22. 12 Carpenter WT, Heinrichs DW, Alphs LD: Treatment of negative symptoms. Schizophr Bull 1985:11: 440-452. 13 Thurm I, Haefner H: Perceived vul nerability. relapse, risk and coping in schizophrenia - an explorative study. Eur Arch Psychiatry Neurol Sci 1987;237:46-53'
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1 Blankenburg W: Autonomie- und Heteronomie-Konzeptc in ihrer Be deutung für die psychiatrische Pra xis; in Janzarik W (ed): Psychopa thologie und Praxis. Stuttgart. Enke, 1985. pp 29-46. 2 Morrison R. Beilack A: Social func tioning of schizophrenic patients: Clinical and research issues. Schizophr Bull 1987;13:715-725. 3 Ciompi L. Dauwalder JP. Ague C: Ein Forschungsprogramm zur Re habilitation psychisch Kranker. III. Längsschnittuntersuchung zum Re habilitationserfolg und zur Progno stik. Nervenarzt 1979;50:366-378. 4 Matson J: Behaviour modification procedures for training chronically institutionalized schizophrenics: in Hersen M. Eisler R. Miller R (eds): Progress in Behavior Modification. New York. Academic Press, 1980. vol 9. pp 167-204.
23 Hogarty G, Anderson C: A con trolled study of family therapy, so cial skills training and maintenance chemotherapy in the aftercare treat ment o f schizophrenic patients: Pre liminary effects on relapse and ex pressed emotion at one year: in Strauss J. Boeker W. Brenner H (eds): Psychosocial Treatment of Schizophrenia. Toronto. Huber. 1987. 24 Angermeyer MC, Klusmann D (eds): Soziales Netzwerk. Ein neues Konzept für die Psychiatrie. Berlin. Springer. 1989. 25 Falloon IRH, HahlwegK.Tarrier N: Family intervention in the commu nity management of schizophrenia: Methods and results: in Straube ER. Hahlweg K (eds): Schizophrenia. Concepts. Vulnerability, and Inter vention. Berlin, Springer. 1990. 26 Hoffmann H. Pia D: Zur langfristi gen Rehabilitation sozialpsychiatri scher Patienten: in Ciompi L. Dauwalder HP (eds): Zeit und Psychia trie. Sozialpsychiatrische Perspekti ven. Bern. Huber. 1990. 27 Zubin J: Suiting therapeutic inter vention to the scientific models of aetiology. Br J Psychiatry' 1989:155: 9-14. 28 Gleick J: Chaos - die Ordnung des Universums. München DroemerKnaur, München. 1987. 29 Haken H: Advanced Synergetics. Berlin, Springer, 1987. 30 Ciompi L. Antbühl B, Dünki F. Thomas R: Schizophrenia - chaotic mind? Exploratory investigations on a complex dynamic systems per spective, in press. 31 Thomas R (ed): Kinetic Logic - A Boolean Approach to the Analysis of Complex Regulatory Systems. Ber lin, Springer, 1979. 32 Hoffmann H, Siemers E, Küpper Z: PASS a community based, sys tem-related program for vocational rehabilitation of chronic mentally ills into free enterprises. Rehabilita tion. vol 2,1992.
33 Hersen M. Barlow DH: Single-Case Experimental Designs: Strategies for Studying Behavior Change. New York, Pergamon, 1976. 34 Bachrach L: Assessment of out comes in community support sys tems: Results, problems and limita tions. Schizophr Bull 1982:8:39-61. 35 Schmitz E: Einführung in die Zeitreihenanalyse. Modelle. Software beschreibung. Anwendung. Bern. Huber. 1989. 36 Babloynantz A. Destexhe A: Strange attractors in the human cortex; in Rensing L. an der Heiden U, Mackey MC (eds): Temporal Disor der in Human Oscillatory Systems. Springer Series in Synergetics. Ber lin, Springer, 1987, vol 36, pp 4856. 37 Pflug B: Circadian Rhythmus and Depression: in Rensing L. an der Heiden U. Mackey MC (eds): Tem poral Disorder in Human Oscilla tory' Systems. Springer Series in Synergetics. Berlin. Springer. 1987, vol 36, pp 194-201. 38 Wehr TA. Goodwin FK: Rapid cy cling in manic-depressives induced by tricyclic antidepressants. Arch Gen Psychiatry 1979:36:555-559. 39 Strauss JS: Mediating processes in schizophrenia: Towards a new dy namic psychiatry'. Br J Psychiatry' 1989; 155(suppl 5):22—28. 40 Klosterkötter J: The Development of Schneiderian First Rank Symp toms. Paper presented at the Work shop on Phenomenology of Schizo phrenia, Geneva, September 12-13, 1991. 41 Schiepek G, Schoppek W: Synerge tik in der Psychiatrie: Simulation schizophrener Verläufe auf der Grundlage nichtlinearer Differen zengleichungen, in preparation.
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14 Rothbaum R, Wcisz J. Snyder S: Changing the world and changing the self: A two process model of per ceived control. J Pers Soc Psychol 1982:42:5-37. 15 Liberman RP. Evans C: Behav ioural rehabilitation for Chronic mental patients. J Clin Psychopharmacol 1985;5/3(suppl):8—14. 16 Liberman RP. Jacobs HE, Boone SE. Foy DW. Danahoe CP. Falloon 1RH. Blackwell G. Wallace CJ: Skills training for the community adaption of schizophrenics; in Strauss JS, Boeker W. Brenner HD (eds): Psychosocial Treatment of Schizophrenia. Toronto. Huber, 1987, pp 94-109. 17 Liberman RP. Muescr KT. Wallace CJ. Jacobs HE, Eckman T, Masscl HK: Training skills in the psychiatrically disabled: Learning coping and competence; in Straube ER, Hahlweg K (eds): Schizophrenia. Concepts, Vulnerability, and Inter vention. Berlin, Springer, 1990. 18 Brenner HD, Kraemer S, Hermanutz M, Hodel B: Cognitive Treat ment in Schizophrenia; in Straube ER, Hahlweg K (eds): Schizophre nia. Concepts, Vulnerability, and Intervention. Berlin, Springer, 1990. 19 Liberman RP. Mueser KT. Wallace CJ, Jacobs HE, Eckman T, Massel HK: Training skills in the psychiatrically disabled: Learning coping and competence. Schizophr Bull 1986;12:631-647. 20 Hoffman H: The function of the round table in a community-based outpatient service. Psychiat Prax 1991:18:209-215. 21 Falloon I: Family Management of Schizophrenia. Baltimore, Johns Hopkins University Press. 1985. 22 Leff J: Changing the family environ ment of schizophrenic patients; in Strauss JS, Boeker W. Brenner HD (eds); Psychosocial Treatment of Schizophrenia. Toronto. Huber. 1987. pp 87-93.
Psychopathology 1992:25:139-146
J.P. Dauwaldera H. Hoffmannb Department of Psychology, U niversity of Lausanne, Switzerland; Social Psychiatry Clinic. U niversity of Berne, Switzerland
Chronic Psychoses and Rehabilitation: An Ecological Perspective
Introduction
In a historical perspective one might dis tinguish three major paradigms which charac terize the evolution of thinking in psychopa thology. The traditional paradigm, prevailing
Paper presented at the WPA Regional Symposium: Changing Psychiatry in Changing Societies. Budapest. August 23-25. 1991.
in the first generation, essentially aims at description and classification of psychopathological phenomena. While important ad vances, such as the now internationally ac cepted systems of classification (e.g ICD or DSM) were achieved, the practical relevance
Prof. Dr. J.? Dauwalder Department of Psychology University of Lausanne. BFSH 2 CH-1015 lausanne-Dorigny (Switzerland)
© 1992 S. Karger AG, Basel 0254-4962/92/ 0253-0139S2.75/0
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/7/2018 12:18:47 AM
Abstract Traditional explanatory models, based on core psychological deficits, vulnerability-stress models or distinctions between negative and positive symptoms, may not be sufficient to understand the phenomenon of chronicity. This linear think ing. looking for monocausal explanations, should be replaced by exploring multicausal and circular processes over time, including the individual ecological context of a given patient. Thus, chronicity appears to result much more from endless loops and irreversible bifurcations in its dynamics over time than to be a stable state. Furthermore, the current views on psychopathology and prognosis need to be fundamentally reexamined in the light of this new way of thinking. For under standing and treatment of chronic psychoses, this ecological perspective implies programs which do not focus only on the patient, but look for 'ecological niches’ and interventions favoring synergetics and self-organization within the social networks and at the worksite of a given patient. A recently implemented five-step program for vocational rehabilitation and the corresponding research plan will be presented and dis cussed.
Individually Centered Approaches
A consistent description of specific behav iors that define chronic mental patients sel dom appears in the literature. Despite the convincing evidence of their poor overall so cial functioning, there exist surprisingly few data on the precise nature or the basis of their difficulties [2], In one of our former studies a complex pattern of social and situational vari ables (i.e. unremunerative occupation, un married state, lack of social contacts, higher age, pessimistic expectations but relative sat isfaction with the present situation) appeared to be much more characteristic of such pa tients than any diagnostic or psychopathologi cal variable [3], Similar psychosocial deficits in adapting to life in the community have also been described in subsequent reviews by Matson [4], Anthony and Jansen [5] or Wing [6], Traditional explanatory models, based on core psychological deficits [7], vulnerability-
140
stress models [8, 9] or the distinction between negative and positive symptoms [10, 11] may not be sufficient to understand the phenome non of chronicity. More recently, the hypoth esis has been formulated that certain behav iors usually related to chronicity, such as emo tional withdrawal and reduction of initiative and interpersonal social involvement, could be understood as secondary coping strategies [12, 13], The suggestion of Rothbaum, et al. [14], that such a passive and withdrawn be havior may afford patients a certain sense of control (secondary control), might open ways for more convincing explanations of the spe cific behavior of these patients. Thus, rehabilitation can be directed to help chronic patients change inappropriate coping strategies. According to this view, rehabilita tion should enhance coping skills of the pa tient and reduce stressful influences from the environment. While evidence of the efficacy of specific training of social skills [15-17] and cognitive skills [18] exists, most of the inter vention studies have been performed in clini cal settings, where generalization to normal living conditions has been limited [2, 19], A major shortcoming of the approaches men tioned so far is the prevailing attribution of patients’ difficulties to themselves. While rehabilitaion programs intend to improve pa tients’ skills and abilities to fulfil social roles, they rarely explore the important obstacles and stressors present in the patients’ environ ment.
The Ecological Approach
In our opinion, linear thinking and monocausal explanations of chronicity based solely on patients’ characteristics should now be re placed by a more comprehensive and ecologi cal approach. By exploring multicausal and circular processes over time within the indi
Dauwalder/HolTmann
Chronic Psychoses and Rehabilitation: An Ecological Perspective
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of this approach remained unsatisfactory [1], The second paradigm, which still prevails ac tually, leads to the development of more gen eral explanatory concepts, such as vulnerabili ty-stress models, positive or negative symp tomatology or dynamics of structure. While practical relevance could be enhanced, these approaches mainly suffer from neglecting on going dynamics in the patient’s environment. In our contribution, we will focus on the emerging third paradigm, which tries to un derstand psychopathological phenomena as particular forms of underlying normal psy chological processes, such as coping, self-orga nization and synergetics in continuous adap tation of an individual person to her particu lar environment. More specifically, we will try to understand chronic mental disorders as a process rather than a psychopathological state.
A.H., a 48-ycar-old man. has been in psychiatric treatment since the age of 29. His clinical diagnosis is chronic schizophrenia (disorganized type). Even dur ing his premorbid young adulthood, communication difficulties at work were reported. During 7 years he worked at 5 different places. While living abroad for 2 years he lost contact with his family and former friends. Upon his return he decompensated rapidly and was hospitalized for the first time. Despite re peated efforts by several employers, he systematically lost every job during the next 15 years. The cause was always the same: feeling overwhelmed, he got tense and nervous and finally provoked arguments with his superiors. For 3 years he lived in a sheltered home, where he worked as a gardener. When he lost this shel tered workplace, he was referred to our industrial reha bilitation unit. Careful assessment of his instrumental abilities showed a performance level of about 50% of a normal worker. His main problems resulted from his social behavior with coworkers and superiors. Whereas so cial skills training proved inefficient, the patient was progressively integrated into our community-based ambulatory aftercare setting, which offers continuous case management by a treatment team. This setting provided a 'secondary' social network for him, through regular contacts with caregivers and former patients of the community. His slowly growing confidence in social relations was mainly reinforced by the availabil ity of a drop-in facility called the ‘round table’ [20]. After 10 months of vocational training in our rehabili tation unit, an appropriate ecological ‘niche’ for him in a print factory was found. At present, he continues working half-time, lives independently together with 2 other former patients and regularly visits our ambulatory' aftercare setting. In the print factory, he and his immediate superiors and coworkers get regular support and consultation from the case manager, which is very important for his maintaining his job.
The progressive social withdrawal of this patient, observed for years before his admis sion to our services, was not only due to his psychopathology or inappropriate behavior, but also to his lack of a supportive social net work and traditional ecobehavioral environ ment. His preferred problem-solving pattern resulted in an endless loop of unstable situa tions: whenever he got a job he lost it. A sim plified graphic summary of the ecobehavioral framework for describing the characteristic dynamics between approach (+) and avoid ance (-) interaction process during the prere habilitation phase is shown in figure la. There is now sufficient clinical and scien tific evidence that carefully orchestrated so cial support of the patient’s environment greatly enhances the effectiveness of rehabili tation programs [21-25]. Usually such inter vention programs focus upon the patient’s family. Our experience suggests the added benefits of including systematically all other significant persons (e.g. landlords or cowork ers) from the social network of a given pa tient. For many chronic patients there exists lit tle or no natural social network. In the case of our patient we therefore had to build up a ‘secondary’ social network in our ambulatory aftercare setting, in which the continuous treatment team facilitated communication and cooperation between all significant per sons and coordinated all therapeutic steps [26]. In our perspective this step was necessary to break the vicious cycle described above. The new dynamics created by this extended ecobehavioral environment proved to be stimulating. Though his deficiencies in social behavior could not be fully remediated, he gradually acquired more social and leisure activities as is depicted in figure 1b. The final step in vocational rehabilitation then was to find an ‘ecological niche’, where
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vidual ecological context of a given mentally ill person, rehabilitation will not only focus on a patient’s behavior, but consider his ecobehavioral environment, where chronicity is also maintained and reinforced by inappro priate coping strategies of significant others or adverse situational constraints. The following description of a typical case will illustrate our approach.
a
b
Pretreatment phase
C
Rehabilitation phase
Ecological niche P
N
N
W
Work dem ands more (+) Patient withdraws (-)
Social net supports work (+) Social net dem ands less (-) Work dem ands less (-) Patient approaches social net (+)
d
•
Endless loop
W
Social net supports work (+) Work supports social net (+) Work dem ands less (-) Patient approaches work (+)
f
Stable state
PNO
superiors and coworkers were willing to coop erate with the continuous treatment team which offered reliable support. As described in figure lc, the most important aim was to create a ‘dynamically stable state', despite the persisting deficiencies in social behavior of this patient. The graphic summaries of our treatment phases show that we explored multicausal and circular processes over time within the individual ecological context of this patient.
whether it will be on or off at the next moment - is governed by logical rules derived from the description of interactions in the first part. There result higher order regularities such as an endless loop in the pre treatment phase (d). an opening of possibilities with out stabilization in the rehabilitation phase (e) and a dynamically stable partial rehabilitation in the reinser tion phase (f).
In Search of a New Methodology
Beyond mere description, a more system atic and reliable methodology for the analysis of such ecobehavioral interactions over time has to be found. Traditional etiological mod els in psychiatry focus on genetic, anatomical, neurophysiological, personality or social vari ables. There exist few developmental models exploring temporal relationships and practi cally no ecological models exploring the re-
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/
0 ONO
Fig. 1. Ecobehavioral dynamics between approach (+) and avoidance (-) interaction processes among patient’s behavior (P) and his social network (N) and work situation (W) for pretreatment (a), rehabilitation (b) and ecological reinsertion phases (c). By idealizing the behavior of each element as a simple binary (on or off) variable, there exist eight possible configurations. The dynamic behavior of each variable - that is.
I42
+
O PNW
OOO (
POO
»
ONW
OOW
POW
Opening
*
Social and vocational skills Symptoms and medication management
Social network Social support
Fig. 2. PASS - the system-related vocational reha bilitation program.
course, full rehabilitation success (PNW) might have been preferred. But for our pa tient. because of his lack of interpersonal skills, partial rehabilitation success was an op timal outcome. These new methods for analysis of the complex dynamics of ecobehavioral interac tions stimulate a number of clinically relevant questions: What maintains chronicity for a given patient? Where should our intervention be directed, in order to create new dynamics? What is the optimal rehabilitation success for a given patient? Can the clinicians’ intuition be replaced or completed by such dynamic models? Another shortcoming of usual voca tional rehabilitation becoming apparent from such analyses is the neglect of preparing and maintaining adequate ecological niches for chronic patients in their ‘natural’ environ ment. To transfer these theoretical ideas into practice we worked out an integrated voca tional rehabilitation program shortly de scribed in the following.
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sources or limits which influence the creation of adapted behavioral patterns through activ ity over time [27], Until now, dynamic pro cesses over time have been studied in psychia try at best with time series analysis or path analysis. In modern physics and chemistry, however, a completely new methodology for the study of complex dynamic systems over time has been developed. The findings of chaos theory [28], the work on dissipative structures by Nobel Prize winner Ilya Prigogine or on synergetics [29] are now widely known. In a series of recent investigations exploring their usefulness in the study of schizophrenia these methods have proved to be very promising [30], We used the simplest of these methods, called 'kinetic logic' [31]. The results of the analysis of the ecobehavioral dynamics for our patient across the subsequent treatment phases are summarized in figure ld-f. Given three conditions, being either present (P = adequate behavior of the patient. N = support from the social network: W = support at work) or absent (O = lack of one of these conditions), there exist eight possible configurations. The most probable transitions among these con figurations are shown for each phase. In the pretreatment phase an endless loop or vicious cycle excluding any of the configu rations involving support from the social net work was found. In the rehabilitation phase new configurations became accessible, how ever without stabilization in dynamics over time. In the phase of integration into the eco logical niche, a dynamically stable state (ONW) was found. Such a dynamically stable state results from dynamics over time and not from simple maintenance of a particular con figuration. It describes a homeostatic ecosys tem. In case of a relapse or perturbation, this ecosystem will rapidly restore this configura tion by its own dynamics. In other words, a ‘permanent’ rehabilitation is achieved. Of
The aim of this system-related program which we call PASS - is to achieve optimal vocational and social rehabilitation and to stabilize the chronic patient at a higher level of functioning [32], The P of the logo PASS means person, A stands for vocation (‘Arbeit’) and SS means social system. The complete program has five phases with contin uous ecobehavioral assessments. (1) The trial phase: The 2 weeks’ trial phase in our rehabilitation unit offers opportunities for the patient to become familiar with different fields and demands of work. During this time, the team gets a clinical grasp of the assets, resources and the deficits of the patient. Also the first assessment is performed in order to establish a baseline. (2) Rehabilitation unit phase: During a maximum of 6 months the patient next receives vocational train ing in our rehabilitation unit. During this period the first scries of social skills training is offered. Further more, psvchoeducational information on the nature of mental illness is given to relatives. They are invited to join a group of relatives for all subsequent phases. According to the clinical course and periodic ecobe havioral assessments, the ongoing programme is read justed. (3) Phase of training in enterprise: In order to reduce the ghetto-like situation of former rehabilita tion workplaces, we offer ‘natural’ training places, created in several businesses, trading and industrial companies. The places for training in enterprise are time-limited for each patient from 6 to a maximum of 18 months. For participating companies we offer a ser vice package, including psychoeducational meetings for coworkers and immediate superiors. Furthermore, our mobile rehabilitation team maintains case man agement. with 2 rehabilitation specialists regularly vis iting the companies and giving support to the patients and to the patients and to their superiors and cowork ers. During this phase the patients return twice a week to our unit for a second series of social skills training. If repeated efforts of problem-solving at the work site fail, we take the patient back into our unit. (4) Integration phase:' Lasting a maximum of 6 months, this phase is used for competitive job-finding. Similar to the company participating in the training
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enterprise, the definitive employer will be integrated in the rehabilitation process. (5) Aftercare phase: In the first month at a new job. but also later, psychosocial crises frequently occur. Superiors often show too much patience and effort keepi ng a patient, until they are exhausted and give up. The long-term case management by our mobile reha bilitation team offers crisis intervention aimed at pre venting the loss of the job.
Based on a critical evaluation of this com prehensive program we shall try to find some answers to more fundamental questions.
The Planned Research
Although most researchers recognize the need for multicausal, integrative and processoriented explanations of treatment and reha bilitation. there exists a lack of empirically founded models, especially for chronic men tal disorders. An empirical evaluation of the program, which is supported by the Swiss National Fund, will try to answer the follow ing questions: (1) Will exposure to a coherent set of inter ventions covering the ecological system of a patient lead to an increase and maintenance of his social and living skills, as compared to baseline functioning? (2) Will homeostasis-oriented, cyclical or change-oriented interactions among variables in the ecological system be found, and will these enable a better understanding of the rehabilitative process? (3) Will efficiency of rehabilitation be en hanced by targeted intervention strategies within the ecological system of a patient, if these are based on such process-oriented anal yses? The clinical studies will be centered on two consecutive series of prospective and con trolled multiple-baseline, single-case designs [33] followed each by detailed multidimen sional evaluations of outcome [34], This pro
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An Integrated Vocational Rehabilitation Program
cedure will permit adaptation of the treat ment program in the second series based on the previous experience, as well as multiple comparisons between the first and second se ries, based on time-series analyses [35] and new methodologies, such as the one presented here.
Conclusions
The search for a unique and simple cause for schizophrenia, also induced by the tradi tional paradigm of psychopathological think ing. has proved to be unproductive. If we con sider the now widely accepted need for multicausal, integrative and process-oriented ex planations. there exists a lack of empirically founded models, especially for chronic schizophrenia. To simulate concrete dynamic processes postulated by such models, we need more appropriate tools for quantitative analy
ses. In psychiatry, recent studies on dynamic modeling seem very promising. This applies particularly to studies on schizophrenia. As Strauss [39] pointed out, there exist at least three typical forms of evolution for chronic schizophrenia, which could be best under stood in such a dynamic perspective. Interestingly enough such a dynamic per spective was recently described for the initial phases of acute schizophrenia by Klosterkotter [40], Still more exciting are the very pre cise simulations of Schiepek and Schoppck [41 ], which prove that such an approach is not only feasible but that its outcomes are clini cally highly relevant. Thus we do not feel lonely in our approach, but rather excited about the promising and extremely rich new prospect which is opened before our eyes for a new and better under standing of this terrible condition called chronic schizophrenia.
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