Pluralism in Psychiatry: Diversity and Convergence
Human Systems Therapy for Individuals with Intellectual Disability
G.Gkantona¹, K. Idreou² & N. Paritsis³
- Psychologist, PhD in School & Developmental Psychology, Society for Systems Therapy and Intervention, Greece, firstname.lastname@example.org
- Psychologist, MSc in Family Therapy, Society for Systems Therapy and Intervention, Greece, email@example.com
- Professor of Psychiatry, President of Society for Systems Therapy and Intervention, Greece, firstname.lastname@example.org
The present study focuses on the application of systemic practice towards the enhancement of the adaptive behavior for people with severe pervasive developmental disorders that live in a community house after deinstitutionalization. The intervention consisted of the formation of a controlled stimulus context for the community house as a whole based on the principles of optimal variety and human systems therapy. A repeated measures experimental design revealed statistically significant improvement in the adaptive behaviors of the residents. Thus, the results indicate new directions for systemic therapy in people with mental disorders.
Keywords: Human Systems Therapy, adaptive behavior, deinstitutionalization, pervasive developmental disorders
The present study is a first attempt to implement a Human Systems Therapy approach in ex hospitalized mentally retarded adults in order to improve their level of functioning, as in the review of deinstitutionalization research there is no such a previous study. The theoretical formulation of this approach is based on the following General Systems principles of intelligence development and learning. In particular, development of intelligence is related to environmental stimulation and information in a not linear way. The maximum development is not related to maximum stimulation but to an optimal, less than the maximum one. Especially, the relation between the mental development in children and the amount of information has the form of an inverted U shape. A possible explanation of this phenomenon can be in the context of General Systems and Cybernetics, and in particular through the law of overload of information stress . According to this law, each living system has certain ability to process information. If the environmental information is much more than the ability to process it, then there is an overload of information stress. Such a stress is expected to reduce the effort for learning and development. The amount of information in systems and cybernetics is related to the amount of variety and randomness or disorder . Intelligence development in Systems science is related to variety that is the amount of different states or components. This is related to the law of experience of Ashby  and of the hypothesis of Miller  that the more developed an organism is the more variety of components it has. Furthermore, Prigogine  proved that order is increased in living systems evolution and development.
Under these conditions Paritsis  integrated the contribution of variety and order to evolution, learning and development. In the case of the contribution of amount of information to the development of intelligent systems that we discussed before, this amount of information is related to variety and randomness. This amount up to a point is producing overload of information stress. In order to overcome this disadvantage, Paritsis ,  claimed that the development of intelligence can be further facilitated by introducing order into the system. The order reduces the amount of information that produces stress. At the same time, this amount
of order will increase development, offering an optimal variety for development without stress (. This is so since the component of variety is supposed to contribute to development and not to the disorder related to the amount of information.
According to these theoretical principles, the aim of this research is to investigate the hypothesis that by using General Systems principles referred to the development of intelligence, namely increasing gradually variety together with order will result in the improvement of the adaptive functioning in persons with profound mental retardation and behavioral problems. The General System Principles used for this purpose will be “the law of optimal environmental variety”  and the dependence of improvement from the “environmental increase of variety and order” , .
Method of facilitating development through applications of systemic principles
The community house that participants moved in after their ex hospitalization was named Epakmos and was conceived as an open system. The intervention was based on the following definition of an open system: An open system is “the result of mutual influence between its elements, their properties, their relations, its emergent properties and its environment” . Each of the above parts influences circularly the rest. The definition of the system favors the integrative intervention at many levels (multilevel) of the hierarchical organization of the Epakmos. Knowing that many levels and their members interact, we were able to focus our intervention on important points at each level resulting in a multiplicative effect of our interventions (and not additive). This is possible since the causal relations are circular and it is expected to increase the effectiveness of intervention. More precisely, we were able to intervene at four levels:
- At the level of cells and brain, through pharmacotherapy.
- At the psychological level (emergent properties of the brain functioning). Such as the behavior of the retarded person, of the members of its family and of the members of the stuff.
- The families of the retarded persons.
- The Epakmos as a whole.
- The extended environment of Epakmos such as the finance by the ministry of health, the neighbors, the supporters of Epakmos.
This enables the therapist to take into account the events of the family as external observer and use techniques of the first cybernetics and take into account the observer and use techniques of the second cybernetics. Furthermore, because environment also determines the emergent properties (according to the definition), and the environment includes the social and cultural context, it allows the therapist to use techniques of narrative therapy. For more details of this epistemology and some additional techniques one can see .
The intervention was based on a gradual provision of a relatively small amount of information during the process of learning and adaptability to the new conditions in the Epakmos. This was necessary since the residents of the Epakmos were mentally retarded and they were able to process a small amount of information. For each person there was a different individualized program according to its ability to process an amount of information and the level of functioning each time. In parallel in order to further maximize the rate of development in terms of adaptive functioning there was an increase in order in terms of rules of behavior and weekly program. The target was a further increase in variety without producing increase in the amount of information received by each resident. This enabled us to offer conditions (variety) for relatively quick learning and adaptation, taking into account the low intelligence of the residents with parallel low overload stress (due to high order). In this way, we expected to achieve a development in adaptive functioning also in persons with severe retardation in relatively short time (six months) and at a significant degree.
In order to design and to monitor this process, every week the persons that engaged in realizing the program met and reviewed the problems and the achievements of the residents
one by one. The specialties of this team were a senior nurse, a psychiatrist, a psychologist, a social worker, an occupational therapist, a physical trainer, a part time teacher and a speech therapist. Then according to the case and state of each resident, different persons engaged for the progress of adaptive functioning, and social integration of the residents. During this meeting physical or mental problems were also discussed and confronted either by pharmacotherapy or by other interventions.
The internal order of Epakmos was succeeded through a set of internal prearranged rules, the rules from the European community and the Greek State that financed the community house. Moreover, there were weekly or monthly meetings with the staff: On a weekly basis there were meetings for therapeutic and administrative issues and on monthly basis there were stuff meetings dealing with relational or personal problems, discussing scientific matters and a meeting with the parents of the residents in order to harmonize and improve our actions.
Subjects were 9 men and 4 women who all were residents of the same community residential home and they received 24 hours residential and treatment services. The average age of the participants was 29, 6 years (19 – 44). All subjects came from a national child psychiatric hospital and their average time of hospitalization there was 18.3 years. In 2007 the residential institution of this hospital closed due to the psychiatric reformation. The patients who stayed there for decades moved into community residential facilities although they were not prepared at all for staying in a community-based residential home or the social transition and integration.
According to the psychiatrists of the national hospital and as defined by the DSM –IV-TR  two subjects were diagnosed with profound mental retardation and pervasive developmental disorder, two subjects with profound mental retardation and psychotic symptoms, five subjects with profound mental retardation, two subjects with profound mental retardation and encephalopathy, one subject with psychotic symptoms and one pervasive developmental disorder and problem behaviors. One person had hearing deficits and another one motor problems. Six of them were reported to have seizures at some time in their lives but only one had epileptic seizures at the time of the study. None of them had a major physical illness.
All of them received anti – psychotic and sedative medications. In addition, five individuals took antiepileptic and one anti-depressive medication.
Regarding their verbal skills, two individuals had fluent speech and sufficient vocabulary. All others had limited speech and vocabulary: one had vocabulary estimated to be approximately 50 words, four had vocabularies estimated to be 3 – 10 words and six were nonverbal. As far as behaviour problems are concerned, six reported to exhibit behaviours such as aggressiveness towards stuff or other residents of the house, damaging the property of the house and seven exhibited self injurious behaviour. Two individuals reported to need intermittent assistance in daily living and eleven required significant assistance with all areas of independent living.
Design of improvement assessment
The design is a repeated measures design looking at changes over time. In order to monitor changes in participants’ adaptive behaviours the first assessment carried out six months before the participants moved to the community house (Measurement A), the second one month after participants’ transition in the community house (Measurement B) and six months after living in the house (Measurement C). Assessing participants at six months was decided as it seems it is an adequate period to trace changes in adaptive behaviours for persons that moved from national institutions to community residences .
Vineland Adaptive Behaviour Scales (VABS) 
The VABS is an informant – based measure of adaptive behaviour and it is designed to assess adaptive functioning from birth to adulthood. Four main domains of adaptive behaviour are assessed and each of them is consisted of sub-domains:
- Communication domain: It assesses in a) Receptive sub-domain how the individual listens and pays attention and what he or she understands, in b) Expressive sub-domain what
the individual says, how he or she uses words and sentences to gather and provide information and in c) Written sub-domain what the individual understands about how letters make words, and what he or she reads and writes.
- Daily Living Skills Domain: It assesses in a) Personal sub-domain how the individual eats, dresses, and practices personal hygiene, in b) Domestic sub-domain what household tasks the individual performs, in c) Community sub-domain how the individual uses time, money, the telephone, the computer, and job skills.
- Socialization Domain: It assesses in a) Interpersonal Relationships how the individual interacts with others, in b) Play and Leisure Time sub-domain how the individual plays and uses leisure time and in c) Coping skills how the individual demonstrates responsibility and sensitivity to others.
- Motor Skills Domain: It assesses in a) Gross Motor sub-domain how the individual uses arms and legs for movement and coordination and in b) Fine Motor sub-domain how the individual uses hands and fingers to manipulate objects.
These domains compromise an adaptive composite score and age – equivalent that estimate an individuals performance in comparison to his/her peer group. There is also a fifth domain evaluating Maladaptive Behaviour but it is not used for the adaptive composite score. Every item of the VABS is rated for frequency on a scale of never (0), sometimes (1), always (2).
The VABS has good psychometric properties with reliability coefficients ranging between .80
– .99 , , . Split – half reliability coefficients and Cronbach’s alpha’s coefficients for severely/profoundly mentally retarded children and adolescents are also very high (.94 and
.99 respectively) . In the same study, Bildt et al., suggest that the combined finding of convergent and discriminant validity strongly support the construct validity of the VABS.
The present study focused on the domains of Communication (Receptive and Expressive), Daily Living Skills (Personal, Domestic and Community) and Socialization (Interpersonal Relationships, Play and Leisure Time and Coping Skills).
Since the Motor Skills domain is applicable for children with ages of six and bellow this domain was not used in this study. The subscale Written of Communication domain was not also used as none of the participant had writing skills.
Questionnaire of Demographic and Personal Characteristics
It assesses variables such as age, place of origin, mental status, physical health, medication, etc.
Direct care staff who had worked with the participants of the study for at least 3 months was used as the informants of the VABS in all assessments. A psychologist with doctorate in mental retardation, who was trained on the administration of the VABS, completed the scales while interviewing the direct care staff. Administration took place in a quiet place in the residential home and lasted approximately 20 minutes for every subject. Data was stored in a database for the participants’ evaluation overtime. The basic rights to confidentiality were followed regarding completing the scales and the basic personal information of the participants was kept confidential.
Data were analyzed by the Wilcoxon Signed Ranks Test. The first series of analyses conducted between the measurement that had been taken 6 months before the participants left the institution (Measurement A) and the measurement that was conducted one month after they moved into the residential house (Measurement B). Measurements A and B were compared by the Wilcoxon Signed Ranks Test. Table 1 shows the Z – scores that were obtained, indicating no significant overall differences between measurements A and B for the adaptive functioning domains.
Medians, inter-quartile ranges and Z – scores of Wilcoxon’s Signed Ranks Test in the
comparison of differences between measurement A and B
|Domain||Measurement||Median||Interquartile range||Ζ –score|
|Daily Living Skills||A||35||21,5 – 44||-1,33|
Note: * P<0,05, ** P<0,01, *** P<0,001
The next series of analyses conducted between the measurement that was conducted one month after they moved into the residential house (Measurement B) and the measurement that was taken 6 months after the participants of the study had been moved into the house (Measurement C). Measurements B and C were analysed by the Wilcoxon Signed–Ranks Test. Table 2 shows the Z – scores that were obtained. Significant differences were found for Daily Living Skills Domain and the Socialization Domain.
Medians, inter-quartile ranges and Z – scores of Wilcoxon’s Signed Ranks Test in the
comparison of differences between measurement B and C
|Domain||Measurement Median||Inter-quartile range||Ζ – score|
|C||25||20,5 – 29,5|
|Daily Living Skills||B||25||21-35||-2,41*|
|Note: * P<0,05, ** P<0,01,||*** P<0,001|
This study is a clinical one with the aim of testing if there is a considerable facilitation of improvement in adaptive functioning after the implication of a particular intervention. The results showed no significant differences comparing the functioning of the participants six months before moving to the community house and one month after the transition to the community house, but indicated significant differences comparing the measures one month after the transition to the community house and six months after the movement. Particularly, the differences were in the domains of Daily Living Skills and Socialization. The systemic method applied was based on General Systems Theory principles and it seems that it resulted in adaptive functioning improvement, as was theoretically supposed (Paritsis, 1993).
As the participants lived for a long period in the national institution, which was an environment with small stimulation, it is apparent that the gradual increase of order and variety helped them to activate the possibilities they had, resulting in the improvement of their functioning in the domains of Daily Living Skills and Socialization. The lack of improvement in Communication is to a large extent due to the difficulties in the Expressive sub-domain, as the Receptive sub-domain was also significantly improved. The Expressive sub domain was the
only with no significant improvement, since most of the residents did not had speech abilities at all. The results are the best so far in the literature in that the two research regarding profound mental retardation shown percentage of improvement less than half than in this study ,  and support the use of the particular Human Systems Therapy intervention
Repeated measures in the future trajectory of the participants or a future study with bigger sample will be useful to further
to test the effectiveness of the particular intervention. Moreover, the presence of a control group to compare with in future repeated assessments would contribute to the further evaluation of the intervention effectiveness.
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