The Holistic Model
Written by Aaron T. Beck, MD
The prevailing model of assessing and understanding schizophrenia is based on the NIMH-Measurement and Treatment Research to Improve Cognition in Schizophrenia (MATRICS) test which compartmentalizes the personality into 7 domains (10 total tests) such as attention, processing speed, and working memory (Kern, Green, Neuchterlein & Deng, 2004). Since individuals with schizophrenia perform poorly on these tests, it is inferred that they have deficits or deficiencies in these functions represented by the respective domains.
In contrast to this compartmentalized approach, our holistic model views the individual as unique—with specific aspirations, yearnings, and needs. Moreover, this model is based on the assumption that individuals function in unity. The basic operations including cognition, affect, and motivation are unified and function synergistically. The content of this fundamental paradigm of cognition, affect, and motivation is expressed through modes which are specific states that are attuned to the demands of the situation as well as the individuals’ needs.
Thus, for example, a quiet mode is adaptive when a person is at a concert, whereas conversation and physical activity in such a situation would be maladaptive. While modes are universal in the normal population as well as in the severely mentally ill, these latter individuals, at times, operate in a psychotic mode, including delusions, hallucinations, irrational thinking, and bizarre behavior. At other times, they operate in an adaptive mode.
A common myth about mental illness is that it persists all the time; yet individuals are often observed switching from the maladaptive, psychotic mode to an adaptive mode when participating in an engaging activity such as playing games, dancing to music, or decorating their rooms. The adaptive mode may be inoperative for long periods of time but becomes accessible to activation when the individual is exposed to a situation in which he or she desires to be active.
In summary, our model contrasts with the compartmentalized model embedded in MATRICS. Instead, we conceptualize the holistic model as being based on a united representation of the personality: we focus on modes, provide a dynamic versus a static conceptualization, and base the treatment on the strengths, interests, and aspirations of the individual as opposed the deficits. Therefore, our overarching goal in treatment is to activate the adaptive mode and deactivate the maladaptive mode.
Identifying and working towards achieving one’s aspirations is a key element in inducing the activation of the adaptive mode and further, to begin the pathway to recovery. The aspirations themselves are not as important as the personal significances attached to achieving the aspiration. When we ask these individuals to imagine achieving their aspiration, they often attach meanings in terms of the self in three categories.
- Connection: accepted, belonging, protection by the group or by another individual
- Control of one’s self and the outside world
- Competence, achievement, and success
The significances are then worked into a treatment plan that follows the pathway to realize their aspirations. Individuals are provided with opportunities to achieve the same significances and meanings as their aspirations. For example, an individual had the aspiration to become a firefighter. His therapist asked him what was good about having that occupation. He said it would allow him to help people. His therapist then asked how he might be able to help people right now, and they set a specific plan.
The pathway to aspirations will contain various problems and challenges. The important element is that the challenges along the pathway provide the potential for growth—or at least for mobilizing the individuals’ assets. Trading on the aspirations involves instilling of hope. This is often sufficient to place the individual in the adaptive mode temporarily. The therapist helps the individual plan activities, each of which is designed to fortify the adaptive mode and to reduce the intensity of the maladaptive (psychotic, negative symptoms) modes. With each successive positive experience, the clinician draws conclusions, or elicits conclusions from the individual, that the experience indicates that he/she is effective, in control, and accepted. As the positive self-image becomes stronger, the individual appears more normal for longer periods of time, and then, continuously. Note: it is important that the activities are personalized according to the individual’s interests, tastes, and preferences and are familiar and involve everyday pursuits.
References:
Kern, RS, Green, MF, Nuechterlein, KH and Deng, B-H (2004) NIMH-MATRICS survey on assessment of neurocognition in schizophrenia. Schizophrenia Research 72, 11–19