When most people think of treatment for individuals with severe mental illnesses such as recurrent depression, bipolar disorder and schizophrenia, they imagine physician visits, medications or perhaps some sessions with a counselor. Rarely do they think of drama programs, community college classes or role-play groups for making friends and dating. Yet, there is increasing evidence that these latter types of interventions, part of a field known as psychosocial rehabilitation, are equally important in allowing individuals who are mentally ill to improve functioning and to regain satisfying roles in society.
Leaders within the U.S. and abroad have spoken of the value of psychosocial rehabilitation. In July 2003, Tommy Thompson, U.S. Secretary of Health and Human Services, stated, “Our challenge is to build a mental health care system that is both consumer and family driven and focused on recovery and resilience.” Shortly thereafter, the World Association for Psychosocial Rehabilitation, an international organization active in 85 countries, held its 8th World Congress in New York City.
Dr. Robert P. Liberman was a speaker at this year’s conference and is one of the founders of the field of psychosocial rehabilitation. A faculty member of the UCLA School of Medicine since 1970, he has directed the UCLA Center for Research on Treatment and Rehabilitation of Psychosis since 1977, integrating innovative methods from principles of psychopharmacology, behavior, learning theory and brain-behavior-environment interactions. With his colleagues, Dr. Liberman has produced a series of user-friendly modules for training social and independent living skills for people with mental disabilities. These modules have been translated into 15 languages and are used throughout the world. Dr. Liberman has published over 300 articles, books and chapters, including the standard texts in psychiatric rehabilitation. He has lectured and given workshops in every state of the USA as well as throughout most European countries, Australia, New Zealand, China, India, Japan, Israel and South America. Dr. Liberman surprised the audience when he mentioned that he also has bipolar illness, making his work important to him as a mental health consumer as well as a professional.
ABILITY Magazine‘s editor-in-chief, Chet Cooper, and health editor, Dr. Gillian Friedman, attended the WAPR Congress and were able to speak with Dr. Robert P. Liberman. Dr. Friedman had previously spoken with Dr. Liberman on the telephone, but had never met him in person; as psychiatrists from different fields, they collaborate in treating a mutual patient in Los Angeles.
Chet Cooper: What is the philosophy behind psychosocial rehabilitation and how did you become involved?
Dr. Robert P. Liberman: People who need to function in a society—as opposed to being locked up in an institution—have to acquire a lot of skills and learn to advocate for additional supports and services. Medication in no way can convey or generate those kinds of skills. Achieving this level of competency requires a partnership between patients and professionals with a hefty input from the families.
My work began with the realization during my training 40 years ago that the only way to bring about improvement in the quality of life of people with severe mental disorders is to teach them how to do it all, from learning the skills they need to meet the expectations of society, to galvanizing the necessary supports and services that they need to function even if they don’t have the skills. At the time, I was a resident physician training in psychiatry when the first translations of human learning theory and principles were being made to psychiatry and education. The students of the famous behavioral psychologist, B.F. Skinner, were beginning to publish rather striking benefits in mental patients who were seriously disabled by reinforcing or strengthening positive and functional behaviors while giving less attention to abnormal behaviors and symptoms. These reports were convincing because of the experimental methods that were used and the dramatic effects that were achieved. Principles and techniques of operant conditioning, now used in rehabilitation of all physical and mental disorders, made eminently good sense and were straightforward in their logic and simplicity. In addition, the very same principles had been known for 50 years to be key influences on the development of normal children and the process of learning knowledge and skills in normal adults. I was immediately able to make the connection with my patients’ problems and goals and a light went on for me. ‘Wow,’ I thought, ‘now I have some tools to use that are practical and applicable in my everyday clinical work.’ Coming from an entirely different direction, behavior therapy offered me the prospect of relief from the frustrations and disenchantment I was experiencing in futile efforts to apply the prevailing psychoanalytic concepts to persons who lacked insight and couldn’t even comprehend my verbal interpretations of their bizarre thinking and behavior.
CC: What were your frustrations?
RPL: Under direction from my psychoanalytic supervisors, I would do my very best to find out where my patients hurt and to give them some verbal insight into [what conflicts in childhood may have caused them to have these difficulties.] My supervisors would finally say, ‘This patient really isn’t suitable for psychodynamic or insight-oriented therapy. Wait until next year. Next year you’ll be working with outpatients, more neurotic patients who will be better suited for this kind of therapy. These patients with schizophrenia and manic-depression, just turn them over to the social workers; they’ll make sure that they have a roof over their heads and three squares a day.’
I thought that was unethical. I don’t like to feel helpless. Maybe it has something to do with my own bipolar II disorder. I am absolutely determined to make a difference, to have an impact. Within a year I began applying learning and skills-based methods with my own patients and seeing that they were working, even with the rather primitive techniques I was using at that time.
Dr. Gillian Friedman: What did you discover in your early studies?
RPL: If a person is very functional prior to the development of an illness, whether it’s physical or a brain disorder, and you remove the obstacles to their existing functional capacities, you don’t have to do a lot of teaching. For example, if a person has been sighted all of his or her life and then develops difficulty with vision because of a cataract, if you remove the cataract, the person sees again and can read again. However, in our field, either people never had the opportunity to learn the kinds of skills needed, or they have forgotten the skills or have been reinforced too much by family, friends and professional people as being sick. What’s being reinforced? Even now, the vast majority of programs used by psychiatrists and institutions that serve those with mental illness focus on what people can’t do and what their problems are. It’s a problem-oriented approach, which is drawn from much of medicine. In the medical field, most physicians aim at removing the symptoms, taking out the pathology, surgically or whatever, and then expect that everything will be all right after that. Rehabilitation is not really the zeitgeist, it’s not the value system of medicine in general. I like to focus on what people can do and to build on that, because I’m impressed with the way that learning principles can aid and abet the strengths that individuals have.
CC: You mentioned a partnership between patients and professionals. Who makes up this team?
RPL: It depends on how much any one person wants to do and how many competencies that individual has. I am very comfortable doing social skills training and teaching, and I always involve the families. I teach the families how to [support the small steps toward progress in a positive, nonpunitive way] and how to advocate for themselves. I demonstrate for them, and if they can’t do it, then I do it. I am able to do a lot of what is called case management.
While I do a fair amount on my own, there’s a limit to what any one person can do, so you involve other people who might be working in the same program you are. But the team members must have the competencies. Arts and crafts may in the short-run help some patients have an opportunity to spend their time doing something constructive, but it has very little carry-over effect for other skills. When you have a team, and the occupational therapists on the team are only capable of doing arts and crafts, that is not going to cut it when you have to teach people how to make friends, have conversations, manage their medications and recognize the early signs of relapse. You really need a teaching program and unfortunately there are very few occupational therapists equipped to do that. There are very few psychiatrists who are even equipped to interact in a capable way with teams. Most psychiatrists, like most other physicians—except for surgeons who work on teams in the operating room—are taught to work on a one-on-one basis with patients and not to involve other people in a greater effort to achieve broader goals. So the team composition depends on the competencies that are necessary to teach people how to function at a higher level, to generate the needed resources and services and to facilitate involvement of other people, like families, to compensate for whatever deficits can’t be rectified by skills training.
GF: One difficulty with programs that try to get away from the problem-oriented approach is that it becomes difficult to pay for other services, because the funding is so problem-based. You can get funded for medication management or for individual psychotherapy, but it’s extremely hard to get funded for case-management.
RPL: Yes, but beyond the funding, there are huge numbers of people working with patients who don’t have the competencies. Unfortunately old approaches get perpetuated, because many of the teachers are from the old school. The question is, when is a new generation of teachers going to inseminate new ideas into these fields?
The other problem is that many technicians and lower level staff involved in the face-to-face treating of people with mental illness are not trained at all. They have less than a bachelor’s degree—a high school diploma at most. None of the disciplines in mental health centers and hospitals can train lower-level workers who are having the vast majority of time face-to-face with people with mental illness. It’s like a ripple effect; the result being a lack of acquisition of more effective methods of teaching people how to move on with their lives.
CC: So how does one provide that new curriculum for teaching the teachers or training the trainers?
RPL: Credible consultants who are able to demonstrate the skills involved may be able to develop a rapport with people who may initially have only a very slim interest in this form of therapy. If the consultant also can leverage some motivation with the organizational leadership for learning these new approaches, the managers may stand up and say, ‘You know, we’re going to do it a different way. We’re changing our mission statement. We’re now going to do rehabilitation, we’re going to do teaching, all of us will be educators as well as doctors, psychologists and social workers.’ You then need to continue to provide ongoing consultation and reinforcement for the progress they’re making. But there’s only a handful of people able to do all that; it’s a very arduous task.
CC: Are you able to share any success stories?
RPL: During my lifetime I have seen some really impressive changes. For example, in Japan the stigma against mental illness is so great that if anyone who has a person with schizophrenia in the family allows that to be known by other family members, neighbors or friends, other members of that family will have a very small chance of getting married. Before the war, they actually hid people with serious mental illnesses in cages in their backyards—like dogs. Until very recently they had a number of psychiatric hospitals where people with mental disorders would spend their lives. They were removed from any visible contact with society.When I went to Japan in 1988 as a visiting professor I began to demonstrate these techniques with Japanese patients and it just took off. I did the demonstrations primarily at the University of Tokyo—it’s like the Harvard of Japan—and it has the best physicians, psychiatrists and trainees. Once people saw that patients could learn some of these skills, they took it like food. It was like nutrition to them. Within a few years, they had formed the Japanese Association of Social Skills Training which has developed training programs and persuaded the Japanese health authorities to reimburse this kind of teaching with their national health insurance. It’s now one of the most important modalities in Japan. I continue on as a consultant, visiting there every couple of years.
GF: Were there any contributing factors to their success?
RPL: There was a critical mass of influentials there who really made a big difference. Now they have an organization of several thousand psychiatrists. They have meetings in all the regional associations where they provide training courses and competency exams. It depended upon having fertile ground. The psychiatrists were ready to give up the institutional model, they just didn’t know how to go about helping people transition from hospitals to communities. They were limited to using medication and arts and crafts, making origami. Obviously, that isn’t going to be sufficient to help people get back into the swing of things.
CC: So what you’re saying is that there aren’t a lot of job openings in origami?
GF: What if a family has to work with the resources around them and their psychiatrist has not had much training in psychosocial rehabilitation? What advice would you give that family?
RPL: That brings us to another means of bringing about change in various mental health fields, which is through advocacy from families. I would acquaint them with the alternatives, suggest they bring these methods to the attention of their local health providers, and point out that they are tried, tested and effective. If they don’t get a response, I recommend going to their county supervisors, whoever is doling out the money. National Alliance for the Mentally Ill (NAMI) groups around the county are doing this all the time. I think the most effective way to bring about change is by consumer demand.
To give you one example, 14 or 15 years ago we had a phone call—before the Internet—from some families in rural Oregon. They had heard about our work in rehabilitation and they said, ‘The people here, the mental health professionals and the mental health center are not receptive to that. We can’t get them to be inquisitive and to learn about these things. What can we do?’ They came down for a visit and there happened to be a couple of people in that group who were real go-getters. Maybe they have bipolar II also! And they got the idea, ‘Maybe we can do this; set up a club or learning center and teach our relatives who have mental illness to function.’ So they got all of our modules and they saw how to do it by observation. They had a viable program and it worked out very well. One of the people became a member of the national board of NAMI, and that led to the state becoming more interested. The word got out, we did training throughout the state and now more is being done there. I think family members have a lot of influence. The interest, the ability—which is the name of your magazine—to advocate for change or for something better, often that comes from family members.
CC: I notice you have a magazine featuring Tipper Gore.
RPL: Yes, it’s put out by Eli Lilly, and it’s pretty good. They’re trying to destigmatize mental illness. There’s an article about her work organizing a national mental health awareness campaign.
CC: I have spoken with Tipper a few times. Supposedly, I was the first journalist with whom she actually talked about mental illness and why she got involved.
RPL: I think this is a key element of destigmatization. The only way to really destigmatize things—whether it’s cancer or schizophrenia—is to demonstrate that people can live a better life. That’s what she did. She was clearly a very competent, effervescent and assertive woman who was a mother, a wife and active in politics. She said, ‘By the way, I sometimes in the past have not been as functional as I am now. But see what treatment has allowed me to do.’ So she’s a very good example of being able to recover and overcome the problems that led to her being ill.
CC: You mentioned schizophrenia. How many different types are there?
RPL: No one knows the answer to that question. The only thing that we know is that there are huge differences in the nature of the beast, that is, the age of onset, the severity of symptoms and the capacities of people to recover and have good outcomes. One assumes, as with fevers back 150 years ago, that ultimately there will be many underlying causes and types discovered, just as we now know about the many different infections that can cause fevers. But I think the important thing is that there are enormous individual differences. This is true for any complex disorder.
CC: Do you divide those differences into groups, saying he has Type I schizophrenia or she has Type II?
RPL: You do have that in illnesses like diabetes, Type I and Type II, and that was based on observations there were striking differences in age of onset, symptoms, etc. We don’t have that as much in psychiatric disorders. There’s a certain subset of people who develop schizophrenia after age 55, which was thought in recent years not to be possible. It could be that this particular group, who have successfully gone through many phases of their lives prior to developing the illness, maybe that will be a different disease, like Type I and Type II diabetes. We really don’t know yet. The old ideas about categorizing schizophrenia by the symptom picture, the way people express their abnormalities in thinking and emotion and behavior and so on, have not been fruitful and are no longer considered relevant or of great importance.
CC: But in manic-depressive disorder there are different types?
RPL: Bipolar I and bipolar II. We don’t know they are different types, all we know is they have different pictures, which again focuses on the different degrees of abnormality. They are described as different disorders in the diagnostic manual, but we don’t know whether they are distinctly different, or how different bipolar individuals are from people with current depressions. Of course in our field there’s a merging of bipolar disorder with schizophrenia. We have another word for that called schizoaffective disorder, somewhere in the middle.
GF: In psychiatry, diagnoses describe symptoms, but don’t necessarily tell about causes. We had to come up with a language so that we could communicate about disorders, so that when one psychiatrist is discussing a patient, another can have some idea’without listing every symptom the patient has’what type of disorder is being described.
RPL: These are artifacts of our own limitations in being able to identify and communicate. And yet, that is perhaps beside the point when it comes to abilities, quality of life and functional capacities.
CC: It seems that whatever the type of mental illness, psychosocial rehabilitation addresses each case in its own unique way to satisfy the individual needs of that particular person.
RPL: Yes, that’s where it’s at. Identifying the family life, ability to work, ability to learn new information, education, ability to develop independent recreational activities, interests and motivations. If you do a comprehensive assessment of these things as well as measuring the symptoms, then you can help people improve. It doesn’t matter the name of the illness or where the problem comes from, rehabilitation starts with the person. It gradually teaches the person or provides the support, whether that’s a wheelchair or some kind of supervised residence or supportive work, whatever it might be.
CC: Do you have to identify the mental illnesses in order to prescribe a certain medicine?
RPL: Not really. None of the medications we know about have any specificity. Antipsychotic drugs are effective for people who have psychotic depressions, or who have psychotic symptoms with dementia or Alzheimer’s disease, manic depression and schizophrenia. They are also prescribed for the psychosis that occurs in various kinds of endocrine disorders, biological illnesses, encephalitis and others. The same thing with anti-depressants. They are also very effective in reducing anxiety and helping people have some protection from panic. Despite our limitations and the primitiveness of our ability to understand the causes of these illnesses, or how distinct they are from each other, having an educational and rehabilitation focus can help everybody. I haven’t encountered anybody whom I’ve worked with who hasn’t had some improvement in their level of functioning if the techniques are used in a very careful, systematic way.
CC: You’ve commented that you have bipolar disorder.
RPL: Bipolar II disorder. Again, we’re not sure what that all means. That’s what my psychiatrist has persuaded me I have. My wife seemed to agree with him, and after thinking about it a lot, I think it’s probably correct that I fit that set of symptoms.
GF: At what point in your life did you realize you might have a problem?
RPL: Well, I’ve had depressions since I was a teenager, but I never thought about there being periods of time where I was abnormally overactive and trying to do more than was reasonable. I look back now and I realize there was sort of a constant…that’s how I tend to operate all the time, and I guess at certain times I get more feverish in my activity level.
GF: Was there a point where it interfered with your functioning?
RPL: The only thing that has been brought to my attention about my hypomania is that I would make demands on other people. Since I was in a supervisory role and had a research center, I would crack the whip a lot more, set the goals a little higher for everybody and get frustrated when people weren’t as productive as I was. Some people thought that was great. It kind of served to encourage them to do more. But I guess for those who took a step back maybe I was overdoing it. I would get frustrated with myself, as well as with other people. I didn’t think anything of it at the time, but many years ago I had a number of projects going on, and once or twice a year I would have the project teams come to my home for a wine and cheese celebration. I remember how frustrated I would be because I had so many things I had to do from the time I woke up until three o’clock in the afternoon when everyone was going to come. I was just tearing around, trying to get all the wine, get the cheeses, sweep this, mop that. I’d have a hundred people over for the party. It was just too much.
CC: This was daily?
RPL: (laughs) Fortunately not! That’s why I didn’t have bipolar I, because it wasn’t evident everyday!
CC: And the depression?
RPL: The first depression I remember was probably when I was 16. I remember that because I was learning how to drive, and at some point in that process, I totally lost confidence in myself. You love to drive when you’re 16 years-old! I remember telling my mother that I needed to see a doctor because I didn’t feel right. It felt like—as many people describe depression—a shadow coming around my life. I don’t think I used the term, depressed. I just felt as though I wasn’t in close contact with my environment. I guess that’s why I was concerned about driving. Of course the doctor said, ‘There’s nothing wrong with you.’ Most doctors never even knew what depression was in those days. The next episode occurred’it was a striking episode, most of them were very striking after that—after I graduated from high school. My best friend and I decided we’d go to the Cascades and get jobs at the resorts; that was the crème de la crème for college students. He was a lifeguard and I was a waiter. I remember really looking forward to this. We went to the New York employment agencies, and we were fortunate enough to get jobs. We went up to this resort and I remember waking up the first day, and I was different. First of all, which is characteristic of my depressions, I woke up and had what they call early morning awakening, with a lot of anxiety. I thought, ‘What is going on?’ It was like a terrible, aversive alarm clock going off inside my head, and everything changed, the whole tenor of my life. I just said, ‘What’s happening to me?’ My concentration was off. I doubted I could learn what I had to as a waiter. Every moment of every day for weeks was a very arduous kind of effort. I really had to push myself to do anything.
GF: What brought about a change?
RPL: After about a month, I began to feel competent. I had received positive feedback, tips and so on. In the second month, I felt great. Maybe I was hypomanic, but as I recall, it just felt great because I wasn’t depressed anymore. Then I had repeated episodes. I remember starting medical school and I had this thought, ‘Would I be able to study? Would I be able to learn anatomy and all these things I had to do?’ I went to the college infirmary, and felt there was something wrong with my brain, which was true! (laughs) At the time, these were called functional disorders; they weren’t considered abnormal brain function. I got the clean bill of health. Again, after a few weeks it went away. I had repeated episodes like this. [In medical school clerkships at Johns Hopkins], my last rotation before graduating was in psychiatry. Piece of cake. Relax. No night duty, no on-call. Just go to the clinic, see some patients, learn a little bit of this and that. I woke up the first day of my psychiatric rotation with the same exact symptoms I’ve had in every other episode: early morning awakening, apprehension, not wanting to face the day.
CC: Are you on any medication?
RPL: Yes, I’ve been taking an antidepressant each day for the past eight years. I also take a mood stabilizer each day
CC: What happened to the depression you developed at the end of your medical school years?
RPL: Immediately after graduating from medical school at Johns Hopkins, I began a very busy and demanding medical internship at Bronx Municipal Hospital in New York. It was amazing, but within a few days of plunging into the many challenges and responsibilities that were part of the internship, I felt much better. Even without medication, I had an extraordinarily satisfying and confidence-building year. Subsequently, I conducted research on mood and depression when I worked at the National Institute of Mental Health and discovered that succeeding in activities, solving problems and having satisfying interactions with others are very effective antidepressants. In fact, having successful and satisfying experiences of various types serve as the basis of the effective cognitive and behavior therapies that have been proven in recent years to be effective in combating depression.