Dr. Liberman and Psychosocial Rehabilitation
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
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 societyas
opposed to being locked up in an institutionhave 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 physiciansexcept for surgeons who work on teams
in the operating roomare 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
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 degreea 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 backyardslike 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 Tokyoit's like
the Harvard of Japanand 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
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 callbefore
the Internetfrom 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 abilitywhich is the name of your magazineto 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 thingswhether it's cancer or schizophreniais
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
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 likeas many people describe
depressiona 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 thatafter 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.
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