The International Journal of Psychosocial Rehabilitation

Paradox in Practice?
 
The Rhetoric of Psychiatric Rehabilitation


 

Erica Lilleleht, Psy.D.

Assistant Professor of Psychology
Seattle
University

 



Citation:
Lilleleht, E.   (2005). Paradox in Practice? The Rhetoric of Psychiatric Rehabilitation.  

International Journal of Psychosocial Rehabilitation.  10 (1),  89-103.

 

Contact:
Erica Lilleleht, Department of Psychology, 900 Broadway –
Seattle, WA 98122;  TE: 206.296.5400; FAX: 206.296.2141; E-mail: elillele@seattleu.edu

 

 


Abstract

When psychosocial programs are scrutinized there is a tendency to pay attention to either formative intent or actual practice. What is lost in such dichotomized analyses is an appreciation of the discursive and theoretical transformations that occur as idealized goals are concretized into systematic practice. Using the rhetoric-of-inquiry framework (Foss, Foss, & Trapp, 1991; Nelson, Megill, & McCloskey, 1987) and the formative and practical texts of the Boston University model of psychiatric rehabilitation (Anthony, Cohen, & Farkas, 1990; Anthony, 2002), I argue that three paradoxical shifts occur as psychiatric rehabilitation’s “rhetoric of intent” becomes a “rhetoric of practice.” These shifts are identified and discussed, as are the implications for psychiatric rehabilitation participants specifically, and mental health care in general. 

 Keywords: psychiatric rehabilitation, psychosocial rehabilitation, psychotherapy research, schizophrenia, qualitative research, mental health services.


Introduction

 As we anchor ourselves in the 21st 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). 

What gets lost in these dichotomized analyses is an appreciation of the theoretical and discursive transformations that occur as an approach’s formative intent is translated into systematic practice. Specifically, one has a difficult time determining whether the assumptions that structure a psychiatric approach’s goals are consistent with those structuring its interventions. We tend to assume such consistency exists, but are we justified in this? After all, psychology and psychiatry’s general unwillingness to examine their underlying assumptions, not to mention the logical consistency of their theories and interventions, is well noted by the more philosophically inclined (e.g., Miller, 1992; Wallace, Radden, & Sadler, 1997). Still, resistance aside, such examination seems warranted from a scholarly perspective. Further, it may have particular import for clients and practitioners who are brought into programs of care based upon the strengths of formative intent (e.g., articles and chapters outlining the programs goals and points of emphasis), but whose experiences run counter to their expectations (e.g., Strawbridge, 2002; Beutler, 1997).

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. 

Secondly, the BU approach is well established in both the literature and the field. In the literature, we see Anthony develop this approach in the late 1970’s and early 1980’s, comprehensively articulating it in his text, The Principles of Psychiatric Rehabilitation (1980), updating it in Psychiatric Rehabilitation (Anthony, Cohen, & Farkas, 1990; Anthony, 2002), and elaborating upon it in a variety of articles and chapters (for a listing of articles published by Anthony and colleagues since 1990, see Center for Psychiatric Rehabilitation, n.d.). Its tangible presence in the field is also noteworthy. Indeed, over the past three decades it has become increasingly popular in publicly funded mental health facilities and beyond, frequently emerging as the dominant form of non-medical treatment (Anthony, 2002; Anthony, Cohen, & Kennard, 1990; Cook & Jonikas, 1996; Lamb, 1994; Lavender, 1995; Prendergast, 1995; Hughes, Lehman, & Arthur, 1996).

Finally, it is an approach connected to practices intended to be highly explicit, even transparent. From its early beginnings (Anthony, 1980) to its latest update (Anthony, 2002), its founders and practitioners have gone to great efforts to operationalized how its philosophy is to be enacted in practice. For example, in Anthony’s (1980) first full-length text, discussions of the approach are often accompanied by case examples intended to illustrate and instruct the reader in how to recognize and enact the particulars of the rehabilitation process (e.g., pp. 33-34, 51-53, 62-63). These efforts culminated in the creation and dissemination of three multimedia training packages, each corresponding to a specific phase in the rehabilitation process:

  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.

 Perspective, Materials, and Method

 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).

Because there has been little critical, theoretical analysis of the BU approach’s structure or process, analyzing its rhetorical practices presents itself as a logical starting point (Lilleleht, 2002; for a conceptual analysis for psychosocial rehabilitation as a whole, see Estroff, 1995). Indeed, identifying and understanding the consistent or changing nature of psychiatric rehabilitation language may be an important precursor to analyzing the specifics of lived rehabilitation experience (e.g., through ethnographic or phenomenological research). It may also be a useful aid in interpreting studies that focus on the efficacy of rehabilitation training and practice in general (e.g., quantitative and qualitative outcome, process, and/or fidelity research; e.g., Bond et al., 2000).

 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). 

Practical texts come from the Center for Psychiatric Rehabilitation’s multimedia training packages (Cohen, Farkas, Cohen, & Unger, 1992; Cohen, Farkas, & Cohen, 1992; and Cohen, Danley, & Nemec, 1992). Available to any interested professional or institution, these packages represent one major way psychiatric rehabilitation technology is disseminated. Trainers use these packages to structure training sessions with practitioner trainees, while trainees and practitioners use them to structure the rehabilitation process with clients.

Method
Using the perspective provided by rhetoric-of-inquiry scholarship, I examine the language of psychiatric rehabilitation’s formative and training texts. In doing so, I attend to both what is written and assumed about rehabilitation participants, and how the rehabilitation process is described and reproduced. For example, within and across texts, what emerges as psychiatric rehabilitation’s legitimate foci? That is, which aspects of human experience (usual and unusual) receive attention, which are ignored, and does this remain consistent? Regarding the rehabilitation process, how is this described and ultimately recreated? For example, given that trainees and clients alike are taught to develop their skills through verbally mediated exercises, to what extent and in what way are these verbal interactions structured? Is the level of instruction great or small (are there many rules guiding participants’ speech/writing, or just a few)? Is there an emphasis on specialized terminology or ordinary language? Are discussions to follow any particular rhetorical style (e.g., denotative or connotative, metaphoric or operational, dialectical or propositional)?

 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. 

As one learns from its formative texts, the presence or absence of skill is a defining feature of those who participate in psychiatric rehabilitation. For example, in his first comprehensive text on psychiatric rehabilitation, Anthony (1980) instructs readers that “the main activity for practitioners is to systematically diagnose and teach the disabled helpee the skills necessary to live, learn, and work, while the main activity for the helpee is to perform the skills necessary to live, learn, and work” (p. 30). This can only be achieved through a skills-training approach in which “the rehabilitation diagnosis, as opposed to the traditional psychiatric diagnosis, attempts to identify those specific patient skill deficits that are preventing the patient from functioning more effectively in her or his living, learning, and/or working community” (Anthony, 1977, p. 661).

 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). 

In order to be included in the psychiatric rehabilitation process, these abilities and needs must facilitate the person’s integration back into the living, working, and learning communities of choice. Statements supporting the goal of integration are many, and include the following:  “the goal of a rehabilitation approach should be to provide the disabled person with the … skills needed to live learn, and work in the community” (Anthony, 1977, p. 660); “practitioners of rehabilitation conceive of their goal as restoring the helpee’s former capacity to function in the community, or, as reintegrating the helpee back into the community” (Anthony, 1980, p. 25); “ the goal of psychiatric rehabilitation is to assure that the person with a psychiatric disability possess those physical, emotional, and intellectual skills needed to live, learn, and work in his or her own particular environment” (Anthony, et al., 1983, p. 70); “rehabilitation tries to open the doors of the community and help people develop a prescription for their lives” (Anthony et al., 1990, p. 2; see also: Anthony, 1982, p. 62; Anthony, 1992, p. 165; Anthony & Liberman, 1986, p. 542; Anthony, Cohen, & Farkas, 1982, p. 85; Anthony, Cohen, & Vitalo, 1978, p. 365; Anthony, Kennard, O’Brien, & Forbess, 1986, p. 249; Cohen, Anthony, & Farkas, 1991, p. 184; Rogers, Anthony, & Jansen, 1988, p. 11).

Identifying, developing, and assessing needed skills becomes the means by which participants come to live more integrated, fulfilling lives. Indeed, in the concluding chapter of their 1990 text, Anthony and his colleagues give voice to the holistic and admirable need to “envision a mental health system that does not define people who use the service by labels, but sees them first and foremost as people” (Anthony et al., 1990, p. 221).

As client and practitioner move to psychiatric rehabilitation’s manuals of practice, this emphasis on integrative skill development continues. Interestingly, however, these manuals pursue skill development using a rhetorical style and set of teaching practices that are highly reductive, with a strong emphasis on division for the sake of observation and measurement. Thus, while the formative texts repeatedly speak of “the skills needed to live, learn, and work in one’s environment of choice” (a relatively holistic goal that emphasizes integration of person and place), the training manuals teach participants to identify, divide, subdivide, and evaluate every component of any relevant skill.

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).  

In and of itself this level of specificity might serve a useful purpose. It certainly encourages both client and practitioner to focus on readily observable and seemingly pragmatic aspects of human existence (individual and environmental), and to do so in a systematic way. The problem, however, comes with the next level of division.  Each of the three steps necessary to identifying critical skills (i.e., inferring behavioral requirements, specifying personally important behaviors, and analyzing critical skill strengths and deficits) requires successfully completing another set of substeps.

For example, in order to adequately “analyze critical skill strengths and deficits,” the third step in developing the list of skills that are to be the focus of the rehabilitation process, client and practitioner move through three specific substeps: 1) “brainstorm the skills needed to produce essential behaviors;” 2) “choose the critical skills;” and 3) “estimate the client’s functioning” (Cohen et al., 1992, “Reference Handbook – Listing Critical Skills,” p. 42).

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).

This avoidance of technological language may also reflect psychiatric rehabilitation’s oft-cited preference for practice over theory. We see this preference in the directive that “the rehabilitation practitioner’s interest in the issue of causation [regarding skill deficit] is at this time more a theoretical than practical concern” (Anthony, 1980, p. 30). We also see it in the explanation that “psychiatric rehabilitation practice uses a variety of techniques based on functional effectiveness rather than theoretical allegiance” (Cohen, Anthony, & Farkas, 1991, p. 188). Indeed, the deliberate use of familiar language, especially in the formative texts, seems to be a reminder that psychiatric rehabilitation is tied to no underlying theory of mental illness, and therefore has no need for specialized terminology (Anthony et al., 1990, p.66).

Once again, however, as formative intent moves to practice an interesting shift occurs in the program’s rhetoric. Although its training manuals never rely on specialized language, they are written in a highly positivistic manner (indeed, the above examples serve as excellent illustrations). That is, the language of these manuals embeds participants in way of thinking, writing, and speaking that attempts to be completely visible, totally operational, stripped of all inference and metaphor. In doing so, the training manuals essentially create a discipline-specific language by imbuing the most general, commonly used words with rehab-specific meanings.

 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.  

The problem with paradox is that it renders straightforward action and reaction, thought and emotion, quite difficult for the person to whom the communication is directed. To be on the receiving end of a paradoxical communication is to find oneself at best confused, and at worst, in a state of intellectual, emotional, and/or behavioral paralysis. It is my hypothesis that both possibilities must be considered when psychiatric rehabilitation intent stands alongside its manualized form of practice. In other words, the paradoxes of divided integration, dependent independence, and unfamiliar familiar language all have the potential to affect the lived experiences of psychiatric rehabilitation’s participants (be they trainers or trainees, practitioners or clients). Furthermore, while this structuring may ultimately enhance the development of the approach (e.g., resulting in a highly systematic, operationalized set of practices), it may be less than beneficial for its designated participants. If this proves to be the case, it would not be novel. Rather, psychiatric rehabilitation would join ranks with other social practices where benevolent intent falls victim to the demands necessitated by program survival and success (e.g., Leyerle, 1994; Spitzack, 1990; Parker, Georgaca, Harper et al., 1995; Caputo & Yount, 1993; Scull, 1989).

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? 

Similarly, the paradox of dependent independence raises the question of whether autonomy (in clients and practitioners) is really desirable after all. Such ambivalence is nothing new, as North Americans (sharing, to some extent, a cultural identity built around an odd mix of rugged individualism and rigid conformity; Bellah, Madsen, Sullivan, et al., 1996) have long struggled with how to control the “deviants” among them, and when, if ever, to set them free or render them responsible (Grob, 1994; Rothman, 1990). In their formative texts, psychiatric rehabilitation authors acknowledge some of this ambivalence, taking the common-sense position that some dependence is necessary if skills are to be taught, and personal choices about living, learning, and working, are to be achieved. However, in creating training manuals that utilize a rhetorical style almost obsessive in detail and lockstep in structure, might it not become difficult for participants to actually achieve independence from the rehabilitation process? If so, how might this be negotiated by someone like Jordon (1995), haunted by “one particular friend, the Controller” who demands more and more of her time listening to his demands such that her own “thinking become more and more fragmented” (p. 502). Or by the person who finds “emotions tremendously complex, and [is] quite acutely aware of the many over- and undertones of things people say and the way they say them … [such that] I have difficulty handling situations that require me to be too artificial or too careful” (Hatfield & Lefley, 1993)? Is it possible to successfully negotiate such structured relationships if yours is a lived-experience acutely sensitive to and disabled by such structures? And for those of us less affected by such structured and structuring relationships, might this lead us to wonder whether independence exists more as an illusion, a technique to keep the participants engaged, motivated, and productive within the rehabilitation process? At the very least, one is left feeling that the manual-based practice is running counter to its formative intentions.

This brings us to the paradox of unfamiliar familiar language. Although participants will not find themselves confused by unfamiliar terminology, as they enter the training and practice of rehabilitation, familiar words do start seeming strange. Again, this bears an eerie similarity to how some people with schizophrenia describe their own relationship with language. Consider Artaud (as cited in Sass, 2004) for whom “all languages go dry, all minds parched, all tongues shrivel up” (p. 312). Or Renee (Sechehaye, 1979), who describes her experiences of everyday objects as follows: “I said ‘chair, jug, table, it’s a chair.’ But the words echoed hollowly, deprived of all meaning; it had left the object, was divorced from it, so much so that on one hand it was a living mocking thing, on the other, a name, robbed of sense, the envelop robbed of content” (p. 56). Just as Renee’s focus on the words themselves render their lived meanings elusive and even mocking, the rehabilitation manuals’ numerous language exercises render implicit meaning excruciatingly visible. And as each word is given its own rehabilitation-specific meaning, it loses its connection to the larger, non-rehabilitation world. Might this distance/disconnection inhibit the ability to communicate, to talk, with any ease? Even worse, to what degree might it render participation excruciatingly difficult for someone whose “own inadequacy to use language to express what lies buried so deeply inside me, even when I am lucid, makes words a curse that blocks the proverbial light within the tunnel, and I am alone with my darkness” (Ruocchio, 1991, p. 358); and for whom “with each uncommunicated experience, the darkness grows” (p. 358)? If one takes these language exercises seriously, rehabilitation participants may no longer be able to talk with one another without a great deal of pre- and post-reflection, observation, and practice. In this way, speaking, reading, and writing may become more exercises in rehabilitation membership than acts of interpersonal, integrative communication.

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).

Perhaps, then, we must accept the meaningfulness of both sets of assumptions, and test out the degree to which the expected outcomes occur in actual rehabilitation practice, and how rehabilitation participants (client and practitioner, trainee and trainer) deal with them. Indeed, the capacity to identify such situations and their consequences may be particularly important in psychiatric rehabilitation because – to the extent that paradox does produce paralysis – there is the possibility that those closest to the paradoxes may be the least able to articulate them (even when reacting to them). If this is the case, perhaps this analysis can assist in creating a roadmap for more experience-near research. In short, this analysis should be considered a beginning and not an end. Indeed, it would be more than a little ironic if this text-based, somewhat disembodied method were to produce the final word on what appears to be a potentially fragmenting and disembodied experience.

 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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