Erica Lilleleht, Psy.D.

 

 

Introduction

 As we anchor ourselves in the 21^st century, we are increasingly aware of the social, fiscal, and familial problems that accompany mental illness.  At the same time, however, mental health professionals are persistently thwarted in their attempts to develop thoroughly effective remedies. In spite, or perhaps because, of this, several hundred approaches to psychotherapy exist (Corsini & Wedding, 2000), pharmacological and other medical interventions are increasing in number and popularity (Burns, et al., 1999; Keen, 2000), psychiatric hospitalization remains a highly utilized treatment avenue (e.g., Clarke, Herinckx, Kinney, et al., 2000; Conte, Ferrari, Guarneri et al., 1996; Haywood, Kravitz, Grossman, et al., 1995), and community mental health programs continue despite funding challenges and low visibility (Stroul, Pires, Armstrong, & Meyers, 1998).
 
Interestingly, when any of these approaches are scrutinized (by contemporary observers or historians), there is a tendency to examine either formative intent (e.g., the approach’s goals, stated and unstated, general and particular), or the specifics of actual implementation (e.g., does the program work, is it administered correctly, what external and internal forces affect application and outcome?). An example of the former critique comes from the antipsychiatry movement of the 1960’s and ‘70s. Encompassing a diverse group of scholars including Szasz, Laing, Cooper, and even Foucault, this “group” questioned the intent of all psychiatric intervention, reframing the goals and activities of its practitioners as various forms of state (e.g., Szasz, 1961), social (e.g., Foucault, 1965), and familial control (e.g., Cooper, 1972; Laing, 1972).
 
Since the late 1970’s, and characteristic of the latter style, evaluations of present and past psychiatric practices have generally become more limited in scope (Brown, 1994). Accepting benevolent intent and eschewing issues of power and control, scholars identified as “process,” “outcome,” “fidelity,” and/or “evidence-based” researchers focus on the actual implementation of interventions in an attempt to answer questions including, “does psychotherapy work as well or better than medication?” (e.g., Seligman, 1995), “which type of intervention is best for which disorder?” (e.g., Nathan & Gorman, 2002), and “are clinicians applying interventions correctly, and if not, why not?” (e.g., Abrahamson, 1999; Crits-Christoph, Baranackie, Kurcias, & Beck, 1991; Luborsky, et al., 1999; Miller, Luborsky, Barber, & Docherty, 1993). This last question, accompanied by the pressures of managed care, has led to an interest in standardizing the activities of practitioners, culminating in an increasing number of manualized approaches (Scaturo, 2001; Beutler, 2000; Bond, Evans, Salyers, Williams, & Kim, 2000; Chambless & Ollendick, 2000; Sperry, Brill, Howard, & Grissom, 1996). 

Exploring the possibility that assumptions can shift, what follows is a textual analysis of a popular and well-documented program, the Boston University approach to psychiatric rehabilitation.¹ Developed by William Anthony (e.g., 1980, 2002) and colleagues (e.g., Anthony, Cohen, & Farkas, 1982, 1990), it is an apt and potentially illuminating choice for the following reasons.
 
First, the BU approach is impressive for its breadth of focus. Designed for persons with severe psychiatric disability [who] have diagnosed mental illnesses that limit their capacity to perform certain functions … and …certain roles” (Anthony et al., 1990, p. 4), this form of psychiatric rehabilitation attempts to provide these individual with “those physical, emotional, and intellectual skills needed to live, learn, and work in his or her particular environment” (Anthony, Cohen, & Cohen, 1983, p. 69). Such a broad focus means that many aspects of life and living are addressed – a valuable asset when assessing whether and how assumptions change as a program moves from intent to practice. 

  1) Setting an overall rehabilitation goal training technology (Cohen, Farkas, Cohen, & Unger, 1992)
  2) Functional assessment training technology (Cohen, Farkas, & Cohen, 1992); and

  3) Direct skills teaching training technology (Cohen, Danley, & Nemec, 1992).

  
In the following analysis I examine the consistency of the assumptions that structure the participants and processes of psychiatric rehabilitation. Through examining the language of psychiatric rehabilitation, I argue that three paradox-producing shifts emerge as its formative intentions are translated into practice. Finally, I put forth some tentative thoughts on the implications of these shifts, for both the participants of psychiatric rehabilitation specifically, and mental health care in general.

 The Perspective: Rhetoric-of-Inquiry
The conceptual perspective for this analysis comes from a type of scholarship known as “rhetoric of inquiry” (Foss, Foss, & Trapp, 1991; Nelson, Megill, & McCloskey, 1987). This multidisciplinary approach has been used to examine the scholarly and applied practices of disciplines including mathematics (Davis & Hersh, 1987), anthropology (Rosaldo, 1987), and psychology (e.g., Eaton, 1999; Madigan, Johnson, & Linton, 1995; Sarbin, 1998; Shotter, 1991). Defined more by a particular attitude towards language than a specific methodology, the rhetoric of inquiry approach rests on the assumption that how language is used reveals a great deal about what that scholar or perspective values and/or assumes, even when there is the claim of being value-free or value-neutral.  Furthermore, understanding how these values are put into action can provide clues as to how inquiry (scholarship) or application (technology) actually proceeds, including where problems lie and how they might be corrected. In the words of John Nelson, Allan Megill, and Donald McCloskey (1987), “within particular fields, rhetoric of inquiry shows what we are really doing and how to criticize it ... Across different fields, rhetoric of inquiry shows what others are doing and how to learn from it” (p. 17).

 Materials
Psychiatric rehabilitation produces two types of texts: formative and practical. Formative texts include full-length books, chapters, and/or articles explicitly concerned with the description, philosophy, and intentions of psychiatric rehabilitation. Although these texts can describe specific practices (e.g., Anthony, 1980), their primary purpose is to present comprehensive and/or specific descriptions of what psychiatric rehabilitation is and seeks to do, as opposed to training readers in the specifics of its “technologies” (see Anthony et al., 1990, pp. 88-91, for a discussion of psychiatric rehabilitation as a human technology). Similarly, while psychiatric rehabilitation’s practical texts may briefly describe intent and/or philosophy, this second set of texts is primarily focused on training mental health professionals and paraprofessionals to engage in its many technologies (Rogers, Cohen, Danley, Hutchinson, & Anthony, 1986).
  
Given the textual nature of this analysis, it is important that both formative and practical materials represent the psychiatric rehabilitation oeuvre. To that end, formative books and chapters are chosen for analysis when they: a) include Anthony as an author; and, b) represent current writings in the area of psychiatric rehabilitation; or c) possess archival importance, as indicated by their being repeatedly cited in more current materials (e.g., Anthony, 1980). Formative articles published in professional journals are selected if Anthony has authorship status, and the journal is recognized within its field as being scholarly and rigorous (e.g., Schizophrenia Bulletin for psychology and psychiatry; Psychological Bulletin and American Psychologist for psychology; Rehabilitation Psychology and Psychiatric Rehabilitation Journal for rehabilitation). 

 All texts are analyzed for the presence and absence of statements and styles that shed light on these questions. Attention is paid to key phrases, repetition, and consistency (or lack thereof), as well as to the use of instruction, specialized language, and rhetorical style. Repetition (verbatim or in terms of essential content and/or style) across texts is taken as an indication of importance, and is noted in the analysis. In many respects the method used is similar to grounded theory (Strauss & Corbin, 1994). For example, the interpretive approach is flexible, and there is a reliance on “inductive strategies for collecting and analyzing qualitative data” with an emphasis on developing inductive theories as a result of the analysis (Charmaz, 2003, p. 82).  There are, however, significant differences. For example, texts instead of interviews provide the qualitative data, and there is no formal coding strategy. Similarly, although the emphasis is always on language, this analysis is not a form of semiotics, as it does not utilize any formal word/phrase counting methodology. As such, it cannot make any definitive statements about importance or centrality from a quantitative perspective. Instead, my approach is much more interpretive, and therefore tentative. I am most interested in examining whether and how rehabilitation language (and the basic assumptions embedded within) changes or remains the same as intention takes action.
 
Results: Paradox

Comparing psychiatric rehabilitation’s formative and practical texts reveal three paradoxical shifts. Regarding psychiatric rehabilitation participants, a paradox emerges which, for the sake of discussion, I term “divided integration.” Regarding the rehabilitation process, two more paradoxes are identified: “dependent independence” and “unfamiliar familiar language.”
  
A Participant Paradox: Divided Integration
Throughout psychiatric rehabilitation’s formative texts, there is an intertwined emphasis on integration and skill development. Integration is one of the overarching goals of the psychiatric rehabilitation process; skill development is one way of achieving this goal (resource development is another; Anthony, 2002; Anthony et al., 1990). Together, these represent psychiatric rehabilitation’s holistic and pragmatic image of itself and its participants. It is an approach that seeks to develop skills in un- or underskilled persons with mental illness, as well as their caretakers (professional or otherwise; Anthony et al., 1990).  Further, these skills are not developed for their own sake, but for the purpose of integrating the individual into her or his community of choice. Paradoxically enough, however, the training manuals employ a rhetorical style and set of teaching practices that emphasize division and reduction. This emphasis is so strong that it becomes difficult to appreciate how any form of integration, be it of a set of skills or of an individual and community, might be achieved. What follows is a tracing of this paradoxical situation. 

 Thus, in psychiatric rehabilitation, clients are not to be understood in terms of symptoms, internal conflicts, or even crisis behaviors, since “psychiatric diagnosis does not predict rehabilitation outcome … diagnostic labeling of psychiatric patients does not provide relevant information about their rehabilitation potential, … [and] inpatient and outpatient interventions that follow psychiatric diagnosis have little impact on rehabilitation outcome” (Anthony, Cohen, & Cohen, 1983, p. 68; see Anthony et al., 1990, pp. 93-99; Anthony, Rogers, Cohen, & Davies, 1995, p. 353).  Instead, the individual is conceptualized according to personal abilities and environmental needs (Anthony, 1977; Anthony, 1980; Anthony & Farkas, 1982; Anthony, Cohen, & Cohen, 1983; Anthony, Cohen, & Farkas, 1982, Anthony et al., 1990). 

For example, wanting to live at home might be divided into the “critical skills” of “disagreeing with sister”, “spot-shopping”, “choosing friends,” “conversing with Dad about topics that interest him,” and “budgeting paycheck” (Cohen, Farkas, & Cohen, 1992, “Reference Handbook – Listing Critical Skills,” p. 8). These critical skills are identified and assessed through a series of language-based exercises in which client and practitioner do three things:  a) “infer behavioral requirements” (that is, what skills does the client need to live at home, from the perspective of the people at home); b) “specify personally important behaviors” (that is, what skills does the client think she should have to live at home); and c) “analyze critical skill strengths and deficits” (which of these skills does the client have or need) (Cohen, Farkas, & Cohen, 1992, “Training Module – Listing Critical Skills,” p. 8).
 
While these three steps help one identify relevant skills, a skill can only be considered critical after client and practitioner determine that it satisfies six criteria. Specifically, the skill must be behavioral (“they appear in the form of actions capable of being seen or heard by others,” Cohen et al., 1992, “Training Module – Introduction,” p. 11), purposeful (“require an understanding of the relationship between the performance of behaviors and the benefits obtained,” p. 15), generalizable (“can be used with different people, in different places, and usually in different situations. There may be specific circumstances in which a person needs to use a particular skill, but the skill can always be used in other circumstances,” p. 15), compound (“composed of both knowledge and behavior…the ability to do a set of actions - i.e., perform an operation - according to both a body of knowledge about what actions to do, why to do the actions, and when to do them,” p. 15), standardized (“mastery can be determined on the basis of comparison of actual behavior with ideal behavior,” p. 15) and stable (“only evidenced in multiple observations of behavior,” p. 16).  

Furthermore, one accomplishes each of these substeps by completing an even smaller set of activities (sub-sub-steps). For example, in order to engage in “brainstorming,” practitioner and client are instructed to “ask the question ‘what are the skills the client needs in order to perform the listed behaviors?’” (Cohen et al., 1992, “Training Module – Listing Critical Skills,” p. 32). Although reasonable in and of itself, even this does not remain an undivided question. Indeed, asking the question properly involves four things (Cohen et al., 1992, “Training Module – Listing Critical Skills”):
 

 1) “trying to list all the possible skills needed for the particular client to produce the behavior…”
  2) “further exploration of [the behavior] to discover underlying skills …”
  3) “thinking about the 3 types of skills – physical, emotional, intellectual – in order to generate skills…”
  4) “thinking about the preparatory skills needed ‘Before’ performing the behavior, the execution skills needed ‘During’ the behavior, and the monitoring skills needed ‘After’ the completion of the behavior” (pp. 32-33).
 

Through utilizing language and constructing experiences that emphasize multiple levels of division, psychiatric rehabilitation’s training manuals seem to reflect the assumption that, when it comes to its participants, what counts are those aspects of experience that can be reduced to their most basic, rehabilitation-specific level. This stands in direct contrast to its rhetoric of intent, which focuses on integration (of skills into the rehabilitation goal, of person into her environment of choice). And the possible results of this divisive discourse?  The person’s original intent, goal, desire (be it the practitioner’s desire to teach her client a productive set of skills, or the client’s desire to live independently) is in danger of becoming lost in a plethora of steps, substeps, and sub-sub-steps.
 
A Process Paradox: The Dependency of Independence
The second set of paradoxical shifts emerges when one examines how the psychiatric rehabilitation texts structure the interactions that make up the rehabilitation process. On the one hand, psychiatric rehabilitation’s formative texts speak of a process that emphasizes independence and autonomy. For example, there is repeated emphasis on integration into the community “given the least amount of support necessary from agents of the helping professions” (Anthony, 1977, p. 660; Anthony, 1980, p. 30; Anthony & Liberman, 1986, p. 542; Anthony, Kennard, O’Brien, & Forbess, 1986, p. 250), “with the least amount of ongoing professional intervention” (Anthony, 1992, p. 165). Although Anthony and his colleagues do stress that “dependence is not a dirty word” (Anthony, 1982, p. 64; Anthony et al., 1983, p. 75; Cohen et al., 1991, p. 189; see also Anthony et al., 1990, p. 68; Farkas, Anthony, & Cohen, 1989, p. 10), their formative texts consistently present psychiatric rehabilitation as a program through which some degree of personal independence can be achieved. 

 

The training manuals, however, utilize discursive style that encourages, indeed insists on, a very high level of dependency. Indeed, as the examples in the previous section suggest, given the level of division and detail involved in the rehabilitation process, it is hard to imagine how this could not be the case. One need only peruse the manuals (remembering that they are intended to parallel the process that occurs between client and practitioner), to realize how minutely the language and actions of all participants are structured. Across all phases of the rehabilitation process, the training manuals instruct trainer, practitioner, and client in precisely what, when, why, and how to speak and behave within the rehabilitation context. These instructions, presented as scripted dialogue, direct both the types of activities one engages in, and the content of these activities (e.g., Cohen, Farkas, & Cohen, 1992, “Training module – Coaching the client,” p. 16). Indeed, across all training manuals, participants are told when to ask questions, make specific points, explain an issue, discuss, and tell what will happen next.

 

One is left wondering whether, given the scripted presentation of these instructions, participants might feel the need to follow and repeat them in a verbatim manner. At the very least, this degree of structure leaves little room for independent, spontaneous, creative thought or behavior. And the question arises as to whether such thought or action, being unregulated and unsystematic, might be considered or source of error or difficulty. 

 

From a textual perspective, then, personal independence appears to be the promised result of a process that is so structured and systematically detailed that it encourages significant dependency. Up to a point, this does not necessarily pose a problem. After all, human beings are social, dependent creatures. We do tend to need each other, particularly when we are in any type of distress. The difficulty, or paradox, of psychiatric rehabilitation is that its formative texts promise reasonable independence as the end result of processes that are not only dependency inducing, but also provide no way of diminishing this intense reliance (on the trainer, the manuals, or the practitioners). Thus, independence runs the risk of existing more as a promise than a lived-reality. How could it be otherwise when there is no transition, no guide for moving out of the intense dependency of the rehabilitation process, and into the relative autonomy of the non-rehabilitation world?
 
Another Process Paradox: Unfamiliar Familiar Language
A final paradox emerges when one examines how language changes as psychiatric rehabilitation’s rhetoric shifts from formative to practical. Interestingly and consistently, both sets of text avoid using technical terminology in favor of non-specialized every-day language. This choice seems intentional, and may reflect psychiatric rehabilitation’s desire to be accessible to a wide-ranging audience (e.g., Anthony, 1992, p. 166; Anthony, Cohen, & Cohen, 1983, p. 77; Anthony, Cohen, & Farkas, 1988; Anthony et al., 1990, p. 129-147; Anthony, Cohen, & Kennard, 1990; Cohen, Anthony, & Farkas, 1991, pp. 199-200; Farkas & Anthony, 1989; Rogers, Cohen, Danley, Hutchinson, & Anthony, 1986).

 For example, the word “skill” becomes “Skill”, a term requiring twelve pages of text to define it, and numerous exercises aimed at assessing the degree to which its user has internalized its “proper/official meaning” (Cohen et al., 1992, “Training Module – Introduction,” pp. 10-21). Furthermore, whenever you are discussing behaviors in relation to a particular skill, you must define them according to a very clear set of rules. Specifically, these discussions must utilize words that are integrated (“describe the unified performance of the individual actions that make up a skill”), interchangeable (“are consistent with the skill name”), fresh (so that you “use words other than the skill name”), brief (“use as few words as possible”), and clear (so that you “can be easily understood by the client”) (Cohen et al., 1992, “Reference Handbook – Describing Skill Use,” p. 13).
 
Other language rules presented in the training manuals address the structure of discourse. For example, in discussing when to use particular skills with your client (referred to as “describing circumstances”), you are instructed to use the “when (situation), with (people), at (place)” format. Additionally, you must make sure that “circumstances are stated beginning with the word ‘Before,’ ‘During,’ or ‘After’”(p. 17).
 
Thus, although the words themselves retain their superficial simplicity, the familiar becomes unfamiliar as implicit, connotative meanings are replaced by highly operationalized, rehabilitation-specific meanings. This transformation seems to rest on the assumption that there is more to the rehabilitation process that meets the eye. Indeed, it implies that there is a level of complexity for which one must be trained, a degree of instruction one must receive in its entirety, and an amount of rehab-specific exercise to experience in order to become an effective rehabilitation participant.
 
Discussion: The Paradox of Practice
A paradoxical communication is one that contains two messages which, taken separately, are logically consistent and meaningful. When taken together, however, they stand in opposition to one another, creating an impossible, if not absurd situation. Respond to the first message and you negate the second; respond to the second and you negate the first. Joseph Heller’s Catch 22 (1955/1996) is perhaps the most widely recognized literary tribute to the paradox. Within psychology, researchers including Watzlawick (1976; with Beavin and Jackson, 1969) and Bateson (with Jackson, Haley, and Weakland, 1956), have studied this form of communication in relation to schizophrenia, depression, and other forms of emotional and behavioral “maladjustment.” And George Kunz (1998), using the work of Levinas, has examined some of the existential paradoxes embedded in contemporary psychology as a whole.  

Consider, for example, the paradox of divided integration. Although clients and practitioners enter the rehabilitation process intending to learn skills that will allow them to successfully integrate into environments of their choosing (and, by extension, allow practitioners back into professional positions of efficacy and respect), this very process risks reducing and dividing lived experience to a potentially irreparable degree. How might this be experienced by someone like the anonymous author BGW (2002), who feels that his “delusions arise from … overanalyzing and articulating ideas” (p. 748); who, in the process of fixing something to eat “would get so tangled up in so many obsessions and compulsions that I could never finish making a meal, usually barely even started it” (p. 750)? Or by someone like Anne (Blankenburg as cited in Sass, 2004) for whom “everything is an object of thought” (p. 307), who speaks of experiencing the world “from somewhere outside the whole movement of the world” (p. 306); who, in the words of Sass, is “unable to stop thinking and questioning the most commonplace facts or axioms of daily life” (p. 307)? Or by Renee (Sechehaye, 1979), who experiences the faces of others (in this case, her analyst) as an amalgam of disconnected, objectified features, “separated from each other: the teeth, then the nose, then the cheeks, then one eye and the other,” with this disconnected “independence inspire[ing] such fear [that it] prevented my recognizing her even though I knew who she was” (p. 51)? As evidenced by the rhetorical practices of its training manuals, psychiatric rehabilitation’s penchant for reduction and division takes whole behaviors out of their lived and largely prereflective contexts and places them under the specialized rehabilitation gaze. All participants and their actions are divided and subdivided, transformed into thoroughly visible part-entities, and given rehabilitation-specific values and expectations. Ironically, in doing so psychiatric rehabilitation may inadvertently and eerily echo some of the pathological experiences it makes such efforts to ignore. This raises several questions. Should psychiatric rehabilitation pay more attention to the phenomenological experiences of its participants (abnormal and otherwise)? Does the approach share anything more in common with the schizophrenic lived-world (in terms of historical and/or cultural factors that might underpin both; e.g., Sass, 1992; Lilleleht, 2002)? And, regardless, is it possible that rehabilitation practice (in contrast to its overt intent) is more focused on teaching participants the skills necessary to continue the rehabilitation process, than on helping participants acquire skills necessary for personal and community integration? 

Conclusion
But what, one might ask, are we to do with these paradoxical shifts? And what are the implications for mental health care in general? Regarding the first question, one possible solution would be to give preference to one set of assumptions over the other. Thus, we could choose to take either psychiatric rehabilitation’s formative texts or its manuals of practice as being truly representative of its developers’ beliefs about mental illness, and their goals regarding their participants. This, however, would be fairly problematic. After all, psychiatric rehabilitation is bound by both sets of texts (some of which are authored by the same people; e.g., Cohen and Farkas), just as Heller’s Yossarian is bound by two sets of consequences (told that he can get out of combat if he asks to be grounded for psychiatric reasons, but that making this request is itself proof of his sanity; 1955/96).

 Regarding the more general question of relevance, although this analysis concentrates on one specific approach to psychiatric rehabilitation, its results raise questions about manualized treatment in general. At the very least, this analysis suggests that certain important transformations can occur as formative intentions are translated into behavioral practice. There are, after all, different pressures and constraints affecting both the development of a psychosocial program’s philosophy of care and the formalization of its practice. And it is not unreasonable to expect that these pressures might find their way into its formal rhetoric. Nor is it unreasonable to hypothesize that such pressures could potentially produce important, although possibly unrecognized, differences between what clients and practitioners are inspired to do, versus what they are instructed to do. This gulf, or rather this strange confluence of diametrically opposed influences, has one set of implications for the participant (e.g., confusion, paralysis, anger) and another for the historically minded observer (e.g., confirmation regarding the self-perpetuating nature of disciplinary power, and the contradictory goals of psychiatric practice). Both implications are potentially significant, and both might be better understood when taking seriously what some consider “just rhetoric.”

_______________________________________
Notes
In choosing to examine the Boston University approach, I am aware of Anthony’s (1994) statement that there never was a “B.U. model” (p. 169).  Although Anthony prefers to define the Center’s work as an “attempt to develop various components of the philosophical, empirical, and technological foundations of the field of psychiatric rehabilitation,” (italics mine, p. 169), his refutation is not consistent with the fact that this approach does maintain a specific philosophy (e.g., Anthony, Cohen, & Farkas, 1982) connected to specific sets of practice (e.g., Cohen, Farkas, Cohen, & Unger, 1992; Cohen, Farkas, & Cohen, 1992; Cohen, Danley, & Nemec, 1992), which can be differentiated from other forms of psychiatric rehabilitation (e.g., Corrigan, 2001; Stein & Test, 1980; Liberman & Foy, 1983). 

 

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