schizophrenia, psychiatric rehabilitation, and healthy development: a theoretical framework

SCHIZOPHRENIA, PSYCHIATRICREHABILITATION, AND HEALTHYDEVELOPMENT: A THEORETICAL

FRAMEWORK

David Starkey, Ph.D., and Raymond B. Flannery, Jr., Ph.D.

This paper makes an initial attempt to present a theoretical model for psychi-atric rehabilitation based upon the principles of healthy development. Themodel emphasizes mastery, attachment, and meaning, three aspects of healthydevelopment that have strong empirical support. A discussion of the impair-ments of schizophrenia related to these three areas is presented, and a reha-bilitation model, The Psychiatric Rehabilitation Integrated Service Model,PRISM, is outlined as an example of a rehabilitation program based upon theprinciples of normal, healthy development.

INTRODUCTION

During the past fifteen years, interest in psychiatric rehabilita-tion has increased. Treatment approaches have stemmed primar-ily from a disease-model approach in which psychiatricrehabilitation from major mental illness is considered similar torecovery from physical illness. Rehabilitation from physicaltrauma requires the help of trained professionals and consider-

The authors are affiliated with the Massachusetts Department of MentalHealth, Harvard Medical School.

Address correspondence to David Starkey, Ph.D., Metro South Area Office,Massachusetts Department of Mental Health, 45 Hospital Road, Medfield, MA02052.

PSYCHIATRIC QUARTERLY, Vol. 68, No. 2, Summer 19970033-2720/97/0600-0155$12.50/0 © 1997 Human Sciences Press, Inc. 155

able effort over time by the afflicted individual before recoveryof function can occur (1). Likewise, functioning can improve andsymptoms decrease when stress is reduced, and coping skills aresupported (2). The emphasis on "function" has to a large degreeprovided the context for all psychiatric rehabilitation interven-tions. While this emphasis has allowed the field to progress inthe area of technical expertise such as the development of "tech-nologies" of rehabilitation and skill training interventions thatfocus on specific areas of need, these interventions have signifi-cant limitations.

In fact, the success rate of current psychiatric rehabilitationinterventions is limited by several factors. The first is that gen-erally only higher functioning individuals, the ones where successis most likely to occur, are chosen for these interventions. Forinstance in state hospital populations, the top thirty to forty per-cent may be funneled into "rehabilitation" programs, while theothers are left to traditional back-ward care (3). Thus those mostin need of rehabilitation may in fact be the least likely to receiveit. Although the philosophy of psychiatric rehabilitation may beto work with the severely psychiatrically disabled, in practice, arelatively high proportion of this group is left out.

A second problem with current practices is the generalizabiltyof what is learned. It is well known that schizophrenics havedifficulty generalizing information learned from one situation toanother (4). One popular method of teaching skills to psychiatricpatients employs a method of pre-test and post-test scores to in-dicate improvement in functioning (5). The tests rely heavily onthe learning of the language of the modules involved. Butwhether this increased knowledge of the terminology about, forinstance, medication, leads to more appropriate or sustained useonce outside the hospital is unknown. Another example involvesthe teaching of social skills, which has been shown to producesome reduction in recidivism according to certain studies (6) . Amore complete and extensive study indicates that social skillsalone have little effect on recidivism if the individual returns toa difficult family situation, and only the addition of intensivefamily interventions in addition to social skills training can helpprevent relapse (7). Thus current social skills training helps those

156 PSYCHIATRIC QUARTERLY

who have a benign social environment, but not those who haveto cope with stressful interpersonal situations.

A great deal of work has gone into increasing specific functionalwork skills (vocational rehabilitation) for the seriously mentallyill. In spite of this, outcomes have not been overly encouraging.While many vocational rehabilitation programs lead to an in-crease in vocational activities while the individual is in the pro-gram " . . . they do not have significant effects on rates ofcompetitive employment after leaving the programs" (8). A diag-nosis of schizophrenia, in particular, seems to predict a poorerresponse to vocational intervention than do other types of psy-chiatric disability(9).

Some of the difficulties confronting psychiatric rehabilitationefforts may derive from the fact that schizophrenia is a braindisease resulting in various kinds of neurocognitive deficits.These deficits may act as "neurocognitive rate-limiting factors"for skill acquisition and attaining optimal adaptation (10).

However, the disappointing outcomes from current rehabilita-tion techniques may also in some degree result from the limitedscope of the interventions used, and the "functional" approachwhich does not take into account what we can learn from thelarger context of psychological theory as a whole. In fact, theway in which psychiatric rehabilitation fits into the larger contextof psychological theory has been generally ignored. For instance,no conceptual framework which anchors psychiatric rehabilita-tion in a model of healthy human development has yet appeared.If individuals attain their highest sense of productivity and sat-isfaction during the course of healthy development, a rehabilita-tion approach based upon these principles should enhance theoverall adaptive ability and quality of life of persons with seriousmental illness beyond what is required to "function" adaptivelyat a task or in a particular setting.

This paper makes an initial attempt to put forward the generalprinciples of healthy development, to discuss how healthy devel-opment is impaired by schizophrenia, and to present a rehabili-tation model, The Psychiatric Rehabilitation Integrated ServiceModel (PRISM), that systematically addresses the areas of mas-tery, attachment and meaning that are the foundation of adap-tive outcomes (11). Thus, this paper attempts to outline an initial

DAVID STARKEY AND RAYMOND B. FLANNERY, JR. 157

conceptual theory in which rehabilitation services are focused oncreating more adaptive coping consistent with healthy develop-ment. Empirical studies examining aspects of this theory will bepresented in subsequent papers.

A MODEL OF HEALTHY DEVELOPMENT

Physicians over the centuries have observed that individuals con-fronted with life stress frequently develop psychological distressand medical illness. Physicians have also noted that some indi-viduals, facing the same or similar stressful events, continueabout their daily activities with minimal disruption in function-ing. Hippocrates, the famous Greek physician, who was con-cerned with the person who was sick, and not the disease alone,stated that he would rather know the person who had the dis-ease, than the disease that had the person (12). Likewise thephysician Galen, born in Asia Minor six hundred years later be-lieved that the qualities of the individual predisposed them tohealth or disease (13).

While medicine and psychiatry have a long and distinguishedtradition of studying the relationship between life stress and sub-sequent illness, the relationship between life stress and sub-sequent health has only recently begun to receive attention.Three sets of empirical studies (11) (14) (15) suggest that rea-sonable mastery, caring attachments to others, and a sense ofmeaningful purpose in life are key domains in maintaining goodhealth in the face of stressful life events.

Hinkle (14) is generally considered to be the first researcherto systematically study healthy persons who coped adaptively andavoided disease. In his studies of telephone operators and tele-phone linemen over a period of twenty years, he documented thathealthy employees coped in two clear ways. First, they tookcharge of their problems and their lives by resolving their ownissues without undue reliance on others. Second, these adaptiveproblem solvers had friends whom they could rely on, and madenew friends when they were transferred to new locations. Rea-


sonable mastery and caring attachments to others appeared tobe significant components in sustaining good health.

In another important series of papers Kobasa (15) and Maddi(16) studied executives in an attempt to identify what skills wereneeded to remain healthy and productive managers. These re-searchers identified three factors that predicted "hardy" person-alities (15). They found that personal control, commitment to atask, seeing problems as challenges rather than as burdens, andhaving social links to others were associated with good health inthese business executives.

Flannery (11) developed the third set of studies in the processof following 1200 middle class men and women over a twelveyear period. Adult evening college students who were rarely illand had a sense of well being were evaluated to assess theirresponses to life stress. Identified as Stress-Resistant Persons,these adaptive men and women were found to employ reasonablemastery in the face of stressful life events; were committed tosomething that was personally meaningful to them; made healthylife style choices that included reductions in dietary stimulants,aerobic exercise, and relaxation exercises; actively sought out so-cial support; viewed life with an occasional sense of humor; andwere concerned for the welfare of others.

These three sets of findings, spanning a forty-year period withdifferent sample populations, differing methodologies, and some-what different operational definitions, are remarkably consistent.All have found reasonable mastery to repeatedly distinguishthose with good health from those with impaired health. All threeof these research projects have found caring attachments to oth-ers to be an additional marker for good health in the face of lifestress. Finally, studies by Flannery (11) and Kobasa (15) havedemonstrated the importance of having a personal, meaningfulpurpose in life (as measured by commitment, concern for others)as an important third marker for good health. These findingsappear true regardless of age, gender or social class (11).

In an era of increasing life stress, these studies offer importantempirical definitions of some of the main factors thought to beassociated with mitigating the potential negative impact ofstressful life events.


CLINICAL IMPAIRMENT IN SCHIZOPHRENIA

A review of the literature on impairment in schizophrenia sug-gests pervasive impairment in mastery, affiliation, and meaning,the very components thought to predict healthy development.

The failure of mastery in schizophrenia may be considered oneof the hallmarks of the illness. Hallucinations, both auditory andvisual, occur outside the control of the individual and are expe-rienced as tangible aspects of reality. Delusions are strongly held,mistaken beliefs, the most common feature of which is persecu-tion by an outside agency. Both often take away all sense of con-trol by the individual. While the latter is sometimes seen as aneffort to regain control of a chaotic, or overwhelming outer world,this control is gained only by the acknowledgment of all loss ofcontrol due to the power of overwhelming external forces. The"aha" experience of the paranoid schizophrenic, for instance, re-sults from an "understanding" of why things have gone wrong,i.e., as a result of the intervention of external forces (17). If thebelief that it isn't one's fault brings relief, the insistence by theindividual that life is not under one's own control is very strong.

Other aspects of schizophrenia include altered perceptions, cog-nitive confusion, attentional deficits, and impaired identity (18)(19) (20). Schizophrenia undermines the sense of continuity ofthe self, produces cognitive deficits that make coping with realitymore difficult, and creates attentional deficits that make under-standing and coping with external reality an almost impossibletask. Schizophrenia is an overpowering illness that substitutescognitive chaos and confusion for predictability and mastery, andundermines the ability to cope by depriving the individual of ba-sic cognitive skills. The loss of control and mastery of even thebasic tasks of daily life can produce a profound sense of help-lessness and loss that compound the effects of having such a dev-astating illness. So called negative symptoms, includingwithdrawal of interest from the outside world, contribute to lossof mastery when the schizophrenic correspondingly loses whatskills he/she might have possessed for coping with that worldthrough atrophy and disuse (21). The institutional lifestyle ofsome schizophrenics, whether in the hospital or in residentialprograms can also contribute to loss of mastery by fostering de-


pendence on others and limiting activity to following a rigid, un-varying routine (22). Opportunities for mastery are lacking andmay not be encouraged, a factor that further limits the experi-ence of being able to act upon the external world in any mean-ingful way.

Disruptions in attachments with others is a second hallmarkof schizophrenia. Social relationships become difficult to form,and more difficult to maintain (2) (23). Deficits in receiving andinterpreting information from others cause confusion, anger andfear. Overly negative interpretations of these communicationsfrom others are common. Likewise, the inner turmoil and lossof control over internal cognitive processes translates into fear-fulness and caution at the social level. Expressive deficits suchas flat affect, decreased facial expression and an inability to ex-press a normal range of human emotions (24) also contribute tothe alienation of the individual suffering from schizophrenia. Re-duced ability to cope with social stressors compounds the senseof isolation as schizophrenics withdraw into themselves as a cop-ing mechanism for reducing social anxiety (2). Schizophrenicsare frequently rejected by their families due to the inability ofthe family to understand or cope with the schizophrenic's un-usual behavior, poor ability to communicate, problems in self-care, or the need to isolate themselves from interpersonal stress(23) (25). The marriage rate and rate of reproduction for schizo-phrenics is much lower than that of the general population (26).Individuals with schizophrenia are often further alienated fromsociety in general because of the stigma attached to their illness.In addition to having difficulty forming relationships, others areless likely to be receptive to the overtures of the person withthis illness due to a perceived "difference" in these individualsrelated to active symptoms, medication side effects, or restrictedlife styles. Persons with schizophrenia also sometimes show littleactive interest in others, a "negative" symptom that further in-creases their isolation.

The ways in which meaning are made by the normal individ-ual, as defined above, are rarely available to those with schizo-phrenia. A very low percentage of these individuals havemeaningful work, or indeed work of any kind (1). Cognitive, per-ceptual, and emotional difficulties make organizing and planning


one's behavior problematic, skills that are necessary for the work-place. Consistency and reliability can also be affected by exacer-bations of the illness. Negative symptoms contribute significantlyto the lack of involvement in meaningful activity due to lack ofmotivation and the energy to succeed. Goals become highly re-stricted, and ambition is often absent. The sense of mastery, withits basis in individual effort, can become a victim of the anergiaand motivationless state created by negative symptoms. Stigmaalso contributes greatly to rejection by potential employers andthe hesitation of individuals with schizophrenia to face this po-tential rejection. If meaning in the life of the individual is definedas playing a meaningful role in society, persons suffering fromschizophrenia are particularly handicapped to overcome both in-ner and societal barriers to meaningful activity.

PSYCHIATRIC REHABILITATION INTEGRATEDSERVICE MODEL (PRISM)

In an effort to address the need for a theoretical model of healthydevelopment as a foundation for psychiatric rehabilitation prac-tices, one of the authors (with the assistance of colleagues atMedfield State Hospital and the Metro South Area of the Mas-sachusetts Department of Mental Health) designed and fieldedThe Psychiatric Rehabilitation Integrated Service Model(PRISM). PRISM focuses on the three areas of mastery, attach-ment and meaning to provide rehabilitation for individuals withmajor mental illness, and, in particular, schizophrenia. This focuson healthy development provides the principles upon which psy-chiatric rehabilitation can hope to be successful in bringing in-creased satisfaction and productivity to those with this frequentlydisabling mental disorder.

PRISM is a system-wide approach to psychiatric rehabilitationthat has been fielded in a state mental hospital. Every patient,regardless of functional level, is presented with opportunities toparticipate in rehabilitation-oriented activities through a patient-oriented treatment approach, ward milieu, day programming andcommunity integration activities.


The PRISM model focuses on mastery through the followinginterventions:

• A strong emphasis on patient participation in treatmentplanning, making patients responsible for developing treat-ment and life goals that are internally motivated.

• The inclusion of patient input into unit and hospital decisionmaking through the development of patient advisory com-mittees, co-led community meetings and participation onhospital committees.

• A curriculum of skill development modules to address func-tional deficits and increase coping skills.

• An overall emphasis on increasing functional skills to com-plement the effects of psychopharmacology, in spite of se-verity of symptoms.

• A unit based approach that attempts to overcome the effectsof institutionalization empowering the individual throughincreased choice as opposed to rigid institutional rules andrestrictions.

• A commitment to work with any patient, no matter whatthe initial level of functioning, to strive toward increasedpersonal mastery in their areas of choice.

The above aspects of PRISM are directed at overcoming thesense of helplessness of the individual with schizophrenia by in-creasing skill development, providing a sense of involvement inthe external world, and avoiding the debilitating skill deficits oflong-term hospitalization.

Next, the PRISM model emphasizes caring attachments withothers in three ways:

• By providing a series of safe situations in which to interactin a meaningful way, consisting of structured settings wherethe content of interactions is limited by the avoidance ofanger and personal issues.

• By emphasizing the development of social skills that reducesocial anxiety and provide rehearsal of skills and in-vivo prac-tice with group support based upon the Liberman model (5).

• By training unit staff to interact in empathic, non-threateningways with this intensely interpersonally phobic population.


By focusing on the multiple areas of ward structures such ascommunity meetings structured for safe interactions, skills de-velopment to increase social confidence, and reinforcement byward staff of social coping ability, affiliation is supported andthe tendency toward isolation created both by schizophrenia andhospitalization are reduced to the extent possible.

Finally, PRISM helps individuals with schizophrenia to focuson creating meaning in their lives by:

• Focusing on their individual goals for living, learning andworking while still in an inpatient setting, and respectingtheir wishes to move forward with their lives even as theyreceive state of the art pharmacological treatment for symp-tom relief.

• By stressing vocational rehabilitation with a Work SkillsModule and work in hospital and community settings topractice needed skills with whatever support is required bystaff.

• By having individuals maintain contact with the local com-munity and the skills required to navigate daily communityactivities.

PRISM supports meaningful activity and relationship to thecommunity as a way of providing support for the creation of in-dividual meaning, and the opportunity for a sense of productivityin a context with other human beings.

CONCLUSION

This paper has presented a discussion of the theoretical basis forpsychiatric rehabilitation practices in the psychology of healthydevelopment using the key concepts of mastery, attachment andpersonal meaning as discussed in the works of Flannery (11),Kobasa (15) and Hinkle and Wolfe (14). These concepts and theempirical work underlying them create a conceptual frameworkand a set of principles upon which to base rehabilitation prac-tices.

The PRISM model described above suggests how the basic ele-ments of healthy development can lead to practical interventions


that guide the psychosocial treatment of the seriously mentallyill, and particularly those suffering from schizophrenia. Thismodel stresses the strengths that underlie healthy development,and how these can be developed and reinforced through a psy-chiatric rehabilitation philosophy that focuses on the basic ele-ments of mastery, attachment and meaning. This theoreticalapproach avoids the potential fragmentation of an approachbased purely upon behavioral "functioning", and creates the op-portunity for individuals with serious mental illness to developin the basic areas that underlie healthy development, leading toenhanced quality of life and sense of self as well as skill acqui-sition.

REFERENCES

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schizophrenia, psychiatric rehabilitation, and healthy development: a theoretical framework

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