Ajai R. Singh MD

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Rehabilitation In Schizophrenia

Published in Thoughts And Reflections: Selected Papers In Mental Health, [Ed. Hema Shah], Vora Medical Publishers, Mumbai, 2006, p 501-513.
ISBN: 81-86361-96-0.

The Is-Ought and Rights-Duties Dilemma, and the Social and Community Psychiatry Interface*



This paper attempts to raise the following questions centering on the concepts Rehabilitation and Schizophrenia: (1) What does it mean to rehabilitate? (2) What it ought to mean to rehabilitate? (3) What does it mean to be a Schizophrenia patient? (4) What it ought to mean to be a schizophrenia patient? (5) Whose responsibility is it to rehabilitate- that of the Society, the mental health professional, the patient? (6) Does the concept rehabilitate reflect the duty of beneficence on the part of caregivers or right to treatment and dignified life for those who need the care, or both? And if both, in what proportion? (7) Is rehabilitation of the Schizophrenia patient at the interface between Social and Community Psychiatry, between Gesellschaft and Gemeinschaft Psychiatry?
The is-ought dichotomy and rights-duty dilemma form the philosophic basis of the conceptual analysis that goes into this paper.


We are all aware there is a dichotomy between what ought to happen and what does, between the ideal and the real. We are also aware that there is a dichotomy and consequent conflict between rights and duties, especially when they confront each other. We also, though often confusingly, talk of Society and Community as two distinct entities.
This paper attempts a conceptual analysis based on these issues with regard to rehabilitation of the schizophrenia patient.

*Revised version of Paper 'Rehabilitation of the Schizophrenic: a philosophical analysis of conceptual issues' read at Symposium: Rehabilitation of Schizophrenic Patients with special reference to the Developing Countries, XIII World Congress of Social Psychiatry, New Delhi, 9-13 Nov., 1992.


What do we mean when we say that we carry out rehabilitation? It means we know what we ought to be doing, we know for whom it is to be done, and we have the necessary expertise, equipment, funds and manpower to carry it out.
Let us consider the first point here, that is, what we ought to be doing (for the others are connected and will be covered automatically). Rehabilitation should involve use of all those forms of physical medicine coupled with vocational retraining, one or other form of residential facilities, and other form of residential facilities, and psychosocial adjustment so as to attain optimal adjustment and functioning. It should involve a purposeful, action-oriented programme ideally involving an activity schedule for the entire day, if necessary in a sheltered, nurturing environment. Such scheduling is to be achieved by the activities prescribed by a physician-psychiatrist with the active involvement of occupation therapy, guidance and counseling, adult education, prevocational shop-training and guided methods of healthy socialization (Hinsie and Campbell, 1970). A wide range of facilities both within and without the hospital are necessary including occupational therapy units of graded complexity, day hospitals, industrial therapy units, sheltered work-shops, good links with sympathetic employers and government units, hostels, boarding houses, and group homes and flats (Bennett, 1978). Moreover, rehabilitation programmes must be designed to prepare the patients for the environment in which they eventually live rather than simply to function during rehabilitation. Rehabilitation is a process that must be continuously applied within the hospital and sustained within the community (Wing and Brown, 1970). All these measures should reinforce the medical treatment programme and retrain a Schizophrenia patient physically, mentally, socially and vocationally for the fullest possible life, compatible with his abilities and disabilities. The goal is to optimize abilities and either reduce disabilities or make them inconsequential.
This is as far as what we ought to do goes. What is it that we are doing? Even the most optimistic appraisal will acknowledge that at each and every step of what we ought to do, there are numerous constraints. We should provide all forms of physical medicine; we do provide some forms, but that is hardly adequate to optimize abilities. We do provide vocational retraining but that often involves fitting patients into traditional work-slots. We do provide facilities for psychosocial adjustment, but the psychological and social environment is hardly amenable to our health promoting efforts. If it were, what was hailed as the third psychiatric revolution would not have had its distressing outcome of trans-institutionalisation to custodial nursing home or the penal system, the revolving door of short-term inpatient facilities and the repetition in the community of the barrenness and isolation that characterized custodial state hospitals. Neither did we attempt to provide them with the skills and supports necessary for full participation in the community, nor did we work with their families to reduce the noxious elements often characterizing that social context (Carson, Butcher and Coleman, 1989).
In such a situation, to think of retraining a Schizophrenia patient for the fullest possible life remains only a utopia, to be immediately watered down by the phrase 'compatible with his abilities and disabilities', which disabilities can become an efficient cover for the disabilities of the caregivers around.
Think of our ideal rehabilitative programme: services such as asylum, housing, socialization, medication and psychotherapy; tailored to individual needs; made culturally relevant; linked with social and welfare services; with specially trained staff comfortable with chronic patients and motivated to deal with them; and proper liaison with acute or long-term hospitals to ensure ready access to hospitalization, if necessary with an internally evolving, constantly evaluating group of care-givers (Okin and Borus, 1989). Apart from spelling it out, let us look around and see how many mental health service programmes come anywhere near this ideal.


Intimately related to this is what it ought to mean to be a Schizophrenia patient. Of course we have come a long way from the times of labeling someone a lunatic and treating him in a dehumanizing manner, for example, chaining him to walls, displaying him for money etc. Philippe Pinel and William Tukes' activism and the consequent moral treatment (The First Psychiatric Revolution) lead to the efforts of Dorothea Dix and transition to the custodial era. With the eye-opening works of Elizabeth Packard (Modern Persecution) and Clifford Beers (A Mind that Found Itself) was heralded the mental hygiene movement supported by Adolf Meyer and William James (The Second Psychiatric Revolution). This has been followed by the era of Community participation, with less of restriction, comprehensive set of services multidisciplinary in nature, active consumer participation, mental health consultancy, and preventive measures which are provided (The Third Psychiatric Revolution). This, however, as we saw, became the fountain source of a fresh crop of problems related to trans-institutionalisation in boarding and halfway houses, with increased rates of hospital readmissions and the 'revolving door syndrome', and further, an ominous rise in the contact between the mentally ill and the criminal justice system.
We have come a long way indeed. But where are we? The minimum expected is that we would by now have evolved a definite set of criteria to diagnose schizophrenia in a patient. Of course we can trace the evolution of our present day diagnostic criteria from the clinical-prognostic 'Dementia praecox' of Kraeplin to the objective-psychopathological 'Schizophrenia' of Bleuler, to the phenomenological approach of Jaspers and the diagnostic approach of Schneider's First Rank Symptoms. The recent well-defined criteria like the PSE-CATEGO, The St. Louis (Feighner's) criteria, the New Haven Schizophrenia Index, and the Carpenter's flexible system have attempted to establish a core syndrome of Schizophrenia by prescribing a set of inclusion/exclusion criteria. But at the same time we have to content with the findings of the US-UK Project where gross differences across nations as to the diagnosis of Schizophrenia came to light. These differences were attributable to the diagnostician, not the patient. No doubt efforts to remedy this are on, one important being the International Pilot Study of Schizophrenics across cultures (WHO, 1973). This has been followed up by a multi-centered project in India on the course and outcome of Schizophrenia (SOFACOS, 1988).
In spite of all this, textbooks have to write, 'What is Schizophrenia has never had a completely satisfying answer' (Menon et al, 1992). And Kubie's contention (1971) is still not fully refutable, 'within the general concept of progressive psychotic disorganization there is no need or justification for a separate subcategory to be called Schizophrenia'. Schizophrenia remains as refractory to consensual conceptualisation and definition as it is to identification of aetiology, prevention and treatment (Karno and Norquist, 1989). And uncertainty about the clinical boundaries of disorders related to Schizophrenia persist (Cloninger, 1989), in spite of the stricter DSM-IIIR criteria; and the ICD 10 (1987) modestly asserts that no strictly pathognomonic symptoms of Schizophrenia can be identified.
Here too, then, what ought to have been settled is in no condition to have been considered settled, even to a reasonable degree.


Let us go to a further point. Whose responsibility is it to rehabilitate? That of society, the mental health professional, the patient? Rehabilitation is an activity carried out by the patient with the help of a professional in a society. The roles of the three are therefore necessarily inter-related. The patient provides the ground and motivation, the professional provides the expertise, and the society provides the environment. They are as interrelated as is the plant, the gardener and the environment for the growth of a plant. If any of these three is lacking, either in potential or in ability, the result will be stunted, anaemic mushrooming, and growth of many weeds, but no strong, healthy plant. If one looks around, examples of such vagrant growth would not be hard to find.
Related to this is the next question. Does the concept rehabilitate reflect the duty of beneficence on the part of care-givers, or the right to treatment and dignified life for those who need the care, or both? We must accept that this is not an either/or situation. It reflects both, for somebody's duty may be somebody else's right. The duty of a care-giver, properly carried out, satisfies the need of a care-receiver. This balance must be kept. But in what proportion? How much of duty will satisfy how much of rights? This is an important question. But it can be answered if the crucial aspect of duty is emphasized and the concept of right understood in relation to it. Duty has a community value; right has an individual, and democratic, value. If the concept of duty is properly realized and practiced, it would decrease the hankering for and preoccupation with rights that has become a major preoccupation today. The proportion in which duties and rights must be combined is the proportion in which they can be digested. For this it is necessary to lay down, first, a set of duties for the mental health professional, the patient, and his primary and secondary group care-givers in the community. That rights that ensue to each after having performed his duties are automatic: they do not have to be sought after. It is, as though, an inevitable result, a fruit that the tree must yield.
This will necessarily be the answer if one studies the rights-duties dilemma down the line, right from the times of Socrates to Kant and even the Utilitarians in the west, to the Vedantin Idealists, the exemplars of Rama and Krishna in the Indian epics, to the Ethical Idealism of the Buddhists and the Pluralistic Realism of the Jainas. This may apparently run counter to the present day preoccupation with rights that is a predominantly democratic value. Rights, by themselves, in isolation of duty, have never been a democratic value. They are intimately and integrally related to duty. They only get highlighted in a democratic set up so duties are performed properly, and thus rights ensured for all.
Be that as it may, because that is not the point at issue here. We may grant that to settle the question of the duty of beneficence of care-givers and the right to dignified life of care-receivers, if the emphasis on both sides is on the duties of each side rather than on their rights which would necessarily and automatically follow from the duties well performed, a lot of the heat and steam from misguided patient-rights movement and protectionist mental health guilds would be eliminated.


Now we come to the last part of this essay. We talk in terms of Social Psychiatry and Community Psychiatry. What is the difference between the two and how are they related? The community (or Ferdinand Tonnies' 'Gemeinschaft') is characterized by intimate primary relationships, with its emphasis on tradition, consensus, informality and close personal ties of friendship and kinship. This pattern of society is most closely approximated by rural agricultural societies. In contrast, Society (or Tonnies', 1887, 'Gesellschaft') is characterized by secondary relations, with its emphasis on formal, contractual, impersonal and specialized relationships. This pattern of society is most typically approximated in the modern urban society, particularly as it exists in large metropolitan areas. The family organization here is weak, emphasis is on utilitarian goals, and the impersonal and competitive nature of social relationships (Theodorson and Theodorson, 1979).
Community and Social psychiatry, to a large extent, have proved true to this subdivision of community and society, of Gemeinschaft and Gesellschaft. What lies at the interface between the two? At the interface between primary and secondary relations, between tradition and modernity, between close kinship ties and impersonal social relationships? At the interface lies transition, and the consequent ambivalence, anomie and loosening of associations that mark all such transitions. That this should be a fertile breeding ground for psychopathology is not a difficult hypothesis to accept. What, however, is germane to the issue here is whether this transition from informal, close traditional ties to formal, impersonal and utilitarian ties is at the root of the difficulties with our rehabilitative and community mental health programmes in general, and those of Schizophrenia in particular. For the community stresses duties, and the society stresses rights. The community stresses what ought to be done, the society emphasizes what is being done. Rehabilitation of the Schizophrenia patient demands what ought to be done, it is a community oriented approach; but it is being implemented in a society which has lost its traditional moorings, and is concerned, and appalled and much as helpless, with what is being done.
This, then, is one of the root causes of the disparity that one observes between what we ought to achieve with our rehabilitative programmes, and what is being achieved here. This is also one of the root causes for the dilemma that surfaces and resurfaces in the form of the conflict of rights and duties, the care-givers' duty with the care-receivers' rights, the care-givers' rights with the care-receivers' duty, the care-givers' duty with his other set of duties, and the care-receivers' duty with his other set of duties. It would of course be interesting to see how Hare's prescriptivism (Hare, 1981), works in this connection, and could become a logical extension of this analysis. But more pertinent to the issue here is whether all the problems that we are encountering with rehabilitation, and rehabilitation of one of the most important afflictions in Psychiatry, that is Schizophrenia, in ultimately related to this dichotomy between Community and Society, this transition which should have been a smooth transfer but instead has become a dichotomy, a separation and consequent conflict of orientations, beliefs and approaches.
The challenge now facing the discipline of Social Psychiatry is to have a better understanding of the interface between the person and his social environment (Henderson, 1988). Already work to an extent is in progress, for example in the recent work of Power and Champion (1986), and Power (1987), who have attempted to study the fit or congruence between a person's habitual cognitive style and his or her current social environment. There is scope for some innovative thinking to develop a theory-driven basis for such social exploration. Then, and then alone, will we be able to prove false the prophesy of Sartorius (1988), that, 'social psychiatry will disappear, and it is likely that this world will be a slightly better place without it'.
How beat to bridge this gap will be the task for all future systems of psychological medicine. In this we must envisage a joint collaborative effort between the mental health care-giver, the sociologist and the philosopher. This paper has been one such attempt, in which the concepts of psychiatry are submitted to philosophical enquiry, and tested on the basis of ethical concepts while interrelating them with sociological ones. This is one logical extension of the call to temper the philosopher's absolutism with the psychiatrist's utilitarianism (Singh and Singh, 1989). This must be the broad framework that we envisage for the start of the Fourth Psychiatrist Revolution if the present day skepticism, ambivalence and confusion in psychiatric theorizing have to diminish to tolerable limits.
I think it opportune to end this paper with this clarion call.


I wish to thank Prof. L.P.Shah for inviting me to this symposium. I also wish to thank Prof. S.G.Mudgal for discussing certain ethical concepts with me.


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