Aftercare rehabilitation is medical treatment, not just social care, for schizophrenia [ Family carers know by experience that sufferers from residual shizophrenia benefit by living within a routine Why that is so, is revealed by all the brain imaging studies on the continuing condition. The brain - the organ of the nind - the brain network connections are often - not always - out of order and not always balanced There fore rehabilitation is about providing the setting for rebuilding and restoring the connections, and for reducing the scope for errors within any re-engagments with those settings. To live with the world outside ourselves, we bring to it accsessible experience selected
and adjusted to meet the requirements of now Because the internal life, carried in the mind networksof sufferers neither always, nor sufficiently, held together, to plan and react to what might lie ahead, sufferers find it hard to successfully start off and maintain their own rehabilitation. How can they - the active brain, the working part of their mind - is often at fault - hampered by reaching for, and holding all the past expereince and skills that allow an outside engagement. Rehabilitation - finding a level of living that protects against relapse, and is meaningful for the future of the individual affected, is what has to be aimed for 'It's about rebuilding and restoring the connections' The tool to achieving this is the one that normally suffices - the active normal brain connections Not now available securely and for long enough to set up the activities, which taking part in, slowly build up the practice in connecting to a routine outside the domicile. The impediment added to by the disuse of the mechanisms for reatarting. The reconncting must come from someone else setting up the appropraite environmental commitment, takin gint o accoiunt - best - wherre the previous interests , experience, and ambitions of the sufferer were once there. They have not kept up with the outside framework of engagement - as in regular work, or regular interest participation. The reason lies in the continuing faults within the illness. The momentum is not held, the leading context is not kept, there in the background for reference, holding in the mind what has to be borne in mind to carry on, to fit in and to adjust on the move forward. Their support system - work attachment, friendships, family understanding - has been broken and left behind. There is anxiety in looking at future changes, and that uncertainty further dislocates the faults in assembling the brain networks, that are necessary for engagment. Help comes from restoring a certain and timely programme of routines outside the self. Where there was a natural interest area, experience and competence, developed before the illness arrived, then with that interest there will still be network of relevant associations to it, held ready for supporting the interest. Re-engaging with those prevous activities will be a good way to revive and expand on the ability to tune in relevant associations. The weakness to connecting is less so , when the intention starts from within - from something the person wants to do. an experimental description of this .... patients with continuing illness did not remember a second task to be done alomgside the first intention, and sometimes tell the observer that they have done something - the second thing expected of them - when they have not done it. Re-engagement in rehabilitation requires a setting and a support that takes account of all this. The priming and preparing internal brain behaviour is lined up by the expectation put in by the signals that come from the external programme.. They have to start again to re-assemble and practice the way of fitting in and going forward.
The connecting process is re-established and exercised, and builds up into a workable framework of recent practice that can be drawn on, in thinking over the hour, day, and week ahead. A programme full of people with residual schizophrenia would not get going socially
.. By March 2002, the written care plan for those people on the enhanced Care Programme Approach must (must!) show plans to secure : ( my under-lining, but 'plans' only )
" ... suitable employment or other occupational activity
adequate housing
appropriate entitlement to welfare benefits.
By March 2004, this requirement will apply to every one on CPA (Care Programme Approach ) ...."
Priebe S, Watzke S, Hansson L, Burns T. Objective social outcomes index (SIX): a method to summarise objective indicators of social outcomes in mental health care. Acta Psychiatr Scand. 2008 Jul ;118(1):57-63.
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see How to behave with schizophrenia .. Those affected by continuing schizophrenia cannot, and do not, engage in many common normal activities on their own initiative, by their own efforts.
They do not, and cannot, sustain the intention in that engagement. They drift into idiosyncratic brain connections , sometimes set on by irrelevant stimuli in their current environment which they are unable to dismiss [ passivity see my ward round quote ]
They lose the advantage that comes in regular weekly work from a continuing access to organised internal reference that has been bult up in practical outside activities , a matching internal network of useful associations from regularly doing something externally.
They drift off line.
The external signposts to behaviour coming from those activities, have lost connection with matching internal processes in their minds.
There is no outside framework of reference - as in the routine of regular engagement at work - to revive those internal associations. Full time work is too much.
The ability to return and flag up the original intention with all the contingencies associated with it, is weakened in schizophrenia - it looks as though the initial background to intention does not carry forward into 'doing it' , so that the direction and association of the intention is not always recovered and is lost to guidance.
When the obligation to connect comes from outside retrieving all the contingencies for that, and storing them in mind, does not happen as fully or as easily as is normally the case.
The struggle to engage is given up, and lack of practice there, loses that ability to keep up with what is going on, and loses the way forward.
This is so for what lies ahead in the next hour, on the next day, during the next week, the year coming up before one; an inner response, is lined up in store, so that the person meets up with the current outside expectation.
Matching what is coming up with the necessary internal response, drawing upon habits built up from experience and stored away to be called up as necessary, is part of ordinary working habits for people in work.
They have acquired and use ' routines', a basic framework, in daily and weekly work, which eases them into organising their personal lives.
People with schizophrenia have not only lost the outside framework of work habits and domestic practice – often with the illness arriving in late teens they cannot have accumulated that experience –People with schizophrenia have spent years 'in the wilderness' losing the use of the relavancies that are needed every day. Where is no internal framework of deliverable expectation, because the internal neuronal connections for that are weakened, disused, never acquired, mislaid or open to misdirection in schizophrenia, then recovery has to start with an external framework.
Because the illness is tiring in itself, this outside framework has to be flexible in duration and complexity, with resting, and the initial framework itself sustained regularly, securely - not broken into by missing personnel changes and timetable changes, and other distractions.
Graduated exposure, reducing anxiety from too great an expectation, starting at the level of attention and concentration that can be accepted and remembered, bearing in mind the intellectual and historical social contexts, and buildng up from them
Rebuilding 'successful connecting' with jobs in hand and with the environment in which these jobs are done – social practices that go with the jobs going on – creates the habits of daily existence which come easily and unconsciously to people with their usual regularity in daily work.
Repetition in acquiring these connections – exercise in the practice of connecting restores 'skills - habits – allows progress in re-connecting in a general way into ordinary life.
The inner brain life acquires intentional skills and 'the will' which 'drives' these is re-awakened. More and more is achieved in a graduated way.
An aftercare of commitment to a weekly schedule is necessary for schizophrenia – a matter of fundamental provision; a basic psychiatric treatment.
Attending to that external expectation in sheltered circumstances, is practice for reviving internal neuronal connection. It builds up connecting patterns inside, builds up internal direction, purpose, future anticipation memories. As these become well established a basis of confident connection is re-established upon which increasing exposure to new experience restores and expands the inner abilities.
In practice ,aftercare provision should have in mind a ' Monday, Wednesday, Friday', routine of flexible half-day, whole day activities: craft, work, art, ducation, training; whatever: occupational activities and interests designed to capture the engagement of someone,
an individual with their own social background, skills, and interests, graded at the level for one who still has the remnants of long term residual illness
- which might breakdown with too high an expectation, or fall away with not enough expectation.
It all has to begin with a basic hinterland steadiness in personal maintenance, personal management , a successful and safe domestic security.
Patients should not carry heightened emotional residues, anxieties arising out of domestic worries, onto outside endeavours.
But for schizophrenia this meaningful external framework is essential - a sine qua non - a 'without which nothing'.
They do need to be amongst other people with 'normalising ' demands, but sheltered and accompanied by people who can 'model' patiently.
'The Journey to Recovery - 'The Government's vision for mental health care' ....
It says this …about the National Standards Framework; page 13