Arnold M Ludwig MD1 and Frank Farrelly ACSW2
Reprinted from American Journal of Psychotherapy
Vol. XXI, No 4 – October 1967

It is becoming fashionable to view mental patients, especially chronic schizophrenics, as poor, helpless, unfortunate creatures made sick by family and society and kept sick by prolonged hospitalisation.  These patients are depicted as hapless victims impotent against the powerful influences which determine their lives and shape their psychopathology.  Such a view dictates a treatment philosophy aimed at reducing all the social and institutional iniquities responsible for the patient’s plight.  However, in the process of levelling the finger of etiologic blame for the production and maintenance of chronic schizophrenia, theoreticians and clinicians have neglected another culprit – the patient himself.  Professionals seem to have overlooked the rather naïve possibility that schizophrenic patients become “chronic” simply because they choose to do so.

Undoubtedly, a myriad of authoritative articles could be quoted to refute such an oversimplified approach to this problem.  We do not deny the complexity of the problem of the multitude of theoretical factors which should be taken into account for the understanding and treatment of chronic schizophrenia.  However, we do claim that all these theoretical considerations have little practical import for the current treatment of these patients.  Since we cannot at this point in time unravel twisted genes, undo the past, reform society, or eliminate mental hospitals, we are left with a more modest, but still formidable task – the treatment of the patient himself.  The major problem is in dealing with what is and not with what should be or might have been.  In our own experience, the problem is not so much modifying factors outside the patient, but rather inc hanging certain patient attitudes and consequent behaviours, as well a complementary, newly traditional attitudes on the part of society and professional staff, which aggravate the basic problem and prevent effective therapeutic intervention.

We have had the opportunity to observe closely and work with a group of 30 male and female chronic schizophrenics, handled with a minimum of medication and housed together on an experimental treatment unit.  In a previous article (1) we outlined a number of characteristic attitudes and behaviours, both on the part of patients and staff, which tended to perpetuate chronicity.  These characteristics comprise what we have called “the Code of Chronicity”.  Implicit in our discussion of the “code” are five important clinical “facts” which, we believe, underlie the behaviours of chronic schizophrenics. 

i. First, these patients can use their insanity to control people land situations. 
ii. Second, they have an indomitable will of their own and are hell bent on getting their own way. 
iii. Third, one of the basic difficulties in rehabilitating these patients is not so much their “lack of motivation” but their intense, negative motivation to remain hospitalised. 
iv. Fourth, insanity and hospitalisation effectively pay off for these patients in a variety of ways. 
v. Fifth, these patients are capable of demonstrating an animal cunning in provoking certain reactions of the part of staff, family, and society at large which guarantee their continued hospitalisation and its consequent rewards.

Related to these characteristics are a number of other important ones, which are typical of these patients and which we want to elaborate on since they are relevant to our basic thesis concerning patient behaviour.  These additional features have gradually come into focus for us during the various phases of our research treatment program; in this article we shall term them the “weapons of insanity”.  It has become increasingly clear to us that patients both have at their disposal and employ effectively an array of counter therapeutic weapons against staff efforts to rehabilitate them.  These weapons not only reach their targets but have the additional bonus of a “fallout” effect in the form of a series of predictable staff reactions.  Since one of the most effective ways to cope with these weapons is

first to recognise them, we have felt the need to describe them and their effects.  Moreover, since we have become convinced that for rehabilitative purposes these weapons of insanity must be jammed, there is a necessity to consider carefully the therapeutic implications and ethical issues involved.  It is our purpose to do precisely this.

The Arsenal of Weapons

Squatter’s Rights

The prevalent conception of mental hospitals as snake pits or horrible asylums from which all patients eagerly long to depart has little trugh when applied to the chronic schizophrenic.  In fact, one of the major problems in rehabilitatin these patients is their adamant refusal to be dispossessed from their adopted hospital homeland.  For many patients, especially those who feel emotionally and financially deprived, the mental hospital represents a “promised land” where the whole range of their needs is met.

The hospital comes to be a model of the idealised childhood home – a cruise on the “good ship Lollipop”.  Every effort is made to help the patient “feel at home”; not only are the basics of food, clothing and shelter provided, but also, as in the good childhood home, his psychosocial needs are met, he is protected from harm and pain, is relieved of any major responsibilities and demands, and has a wide variety of entertainment and recreation provided for him.  His home gives him a ready made group of companions who, because they share similar experience, give him understanding and sense of belonging.  The good parental surrogates never punish him; they attempt to protect him fro failure and frustration, try conscientiously to meet his immediate needs at all levels, and do not expect him, as a child to make decisions for which he is not ready or mature enough.

The hospital thus comes to represent an emotional gold mine where patients stake their claim.  They seem to grasp intuitively the legal dictum that “possession is nine tenths of the law”.  It some claim jumpers, in the guise of therapeutic staff, threaten to dispossess them, especially after their years of homesteading, chronic patients will fight back with animal ferocity to defend their territory.  This general attitude seems best epitomised by the remark of one patient who told the staff “You’ll never railroad me out of here!”

All or Nothing

Ask any patient whether he wants to be rehabilitated and the invariable answer will be “yes”,  try to do anything to effectively bring this about and the invariable behavioural response will indicate “no”.  One reason for this discrepancy between verbalisation and behaviour is that it requires minimal effort to utter the socially appropriate “yes” and maximum effort to do something about it.

There appears to be four basic components to the patients views concerning rehabilitation. 

i. First they sincerely want all the good things, such as status, power, love, material possessions, which can come with discharge.
ii. Second, they want an iron clad guarantee that they will get these good things.  If they are to prepare themselves for leaving the hospital, they want firm assurance that people will accept them, not derogate them for having been mental patients, not hold their behaviour against them, not reject them and treat them with dignity and respect,
iii. Third, they expect the good things to be given to them free.
iv. And forth, they are unwilling to expend any persistent effort or expose themselves to undue frustration to acquire the good things.

Almost any therapeutic staff working with these patients will recognise the “all or nothing” principle in most of their behaviour.  Patients want the whole pie and are often dissatisfied with only one piece of it at a time.  If they have to experience any emotional pain or stress in achieving socially appropriate goals, their most common response is to give up altogether or say “to hell with it”.  This response is reflected in their whimsical work week or their attendance at and participation in any constructive rehabilitation program where they readily throw away all their gains at the slightest frustration or rejection – knowing full well that they can afford to do so since they can always fall back on the good will and beneficence of the hospital.

Most rehabilitation programs for chronic schizophrenics are bound to founder simple because the staff have not come to grips with these patient attitudes and behaviours.  The patients problems may be explained by invoking such scientific terms as low frustration tolerance, infantile omnipotence of the wish, and poor impulse control, but these terms are only substitutional euphemisms for saying that patients want what they want, the way they want it, when they want I, and effortlessly.

Social Push Buttons

It is an interesting phenomenon that “helpless” and “confused” schizophrenics are often much more expert at producing certain reactions on the part of the staff, the family, and society at large than are the latter at evoking desired patient responses.  Because patients have a far better understanding of our social value system with its inherent limitations than we have of theirs, they can employ a repertoire of behaviours which function as push buttons to elicit the desired staff or social response, thereby insuring the attain of their goal.  These patient behaviours and the reactions they trigger off have an “if then” quality to them.  For example, if the patient presents any one of the following behavioural stimuli then it will elicit a specifiable, related staff response with a high degree of probability:

1. Nuisance behaviour evoked irritation and anger;
2. Overt sexual behaviour evokes outrage;
3. Aggressive combative behaviour evokes fear;
4. Self destructive behaviour evokes pity;
5. Stubborn withdrawal evokes frustration; and
6. Crazy bizarre behaviour evokes confusion and helplessness.

When staff, family or society become irritated and angry, outraged, fearful, pitying, frustrated, or confused and helpless, then they are automatically forced to take action in a variety of forms, the end result of which is continued hospitalisation or re-hospitalisation.

In addition to these push buttons there is another more general one which we have termed the “tyranny of the weak”.  It seems to involve a somewhat different kind of process and appears to lead to a “hands off” effect of therapeutic inaction.  When we begin confronting patients and “picking on them” for therapeutic purposes, they portray themselves as helpless and weak, and vulnerable while simultaneously casting the staff in the role of inhumane bullies.  Because they effect this type casting so convincingly, and because we accept these complementary good – bad roles, the consequent shame and guilt aroused in us cause us to withdraw as effectively as does a wolf in response to the exposed jugular vein of another wolf in a fight.  By employing this tactic, patients frequently exploit their “weakness” tyrannically over others by forcing them to make amends for “mistreating” them.

When patients are confronted with or held accountable for these triggering behaviours, they almost always invoke the following ritualistic formulae:

a. I didn’t do it – you did;
b. If I did do it, you made me do it;
c. Even if I did do it, I’m not to blame 0 I’m emotionally and mentally disturbed.

Aside from the apparent reason of assuring continued hospitalisation, it appears that there are three other factors which keep patients pushing these buttons:

1. First, they attain power and recognition.  By pushing any of these buttons, patients can mobilise social agencies, communities, families, and the hospital staff to cope with their behaviour (“I’ll make you pay attention to me”).
2. Second, this affords them a sense of control which reduces their feelings of helplessness and impotence.
3. Third, they continue to push these buttons simply because they are so effective.  People invariably respond to these patient behaviours and unwittingly continue to reinforce them.

The Divine Right of Kings

One of the central problems in treating the chronic schizophrenic centres around the issue of the patients responsibility for his actions.  At the present time, the label of insanity confers diplomatic immunity or sanctuary for all patients deviant behaviours.  Patients can gratify every impulse or whim without fear of serious retaliation.  They have the sanction to indulge any of their feelings because, by definition, they are presumed not to know any better or are unable to control their impulses and, therefore, cannot beheld accountable for what they do.

Not only is the patient immune for retaliation by society, but he can also buy protection form his own conscience for repugnant actions by employing the ultimate excuse of craziness.  Under the sacrosanct banner of insanity, he can avoid guilt and shame for normally shocking or sickening behaviour,.  If he so desires, he can defecate when or where he chooses, masturbate publicly lash out aggressively, expose himself, remain inert and unproductive or violate any social taboo with the assurance that staff are forced to “understand” rather than punish his behaviour.

In many ways, the modern day patient has prerogatives similar to the medieval absolute monarch with the power and sanction to gratify his every whim,  just as the divine right of kings insured that “the king can do no wrong”, so too the mentally ill can do no wrong; they can only engage in “sick” behaviour.

The divine right of the mentally ill confers other advantages.  Like any monarch with his retinue of servants, chronic patients also have a number of helpers or “servants” to wait on them.  In any well staffed mental hospital professional dieticians prepare their meals, and psychiatric aides serve them; should they need some assistance in dressing, shaving or showering some staff person is always available.  Recreational and occupational therapists make details plans to amuse and keep them from becoming bored.  Should they get upset, some doctor or nurse is always nearby to quell their anxiety or relieve their hurts.  Social workers are ready to act as emissaries with their families and diplomatically explain the patients “illness” to elicit understanding and acceptance.  It is not surprising that several patients “delusionally” have referred to us as their servants – that the hospital exists, as in fact it does to take care of them and minister to their needs.

Let the Healer Beware

Even when patients do occasionally apologise or seem remorseful for their actions, they often employ ritualistic confessions with no sustained, firm purpose of making amends.  Their usual behaviour is to do something bad, contritely confess their wrong doing ask for forgiveness, and shortly afterward repeat the same process, sometimes in a different form, which calls into question the credibility of their acts of contrition.  Their behaviour can be summarised in the formula “slap – ‘I’m sorry’ ……. Slap – ‘I’m sorry’ …… slap ………..”  When staff members find these repetitive acts of contrition unbelievable and convey their disbelief to patients, the typical patient response is to become hurt or furious at the staff or not being gullible and naïve enough to accept the magic words “I’m sorry”.

The purpose of the repetitive utilisation of these magic words seems three- fold:

1. First, to be granted a suspended sentence form any guilt or shame they themselves might feel at their behaviour;
2. Second, to placate the staff’s animosity through this show of penance; and
3. Third, to secure the restoration of full privileges.

The Syndrome of “Chronic Staffrenia”

Part of the real difficulty in establishing an effective treatment and rehabilitation program for chronic schizophrenics resides in the reaction of the hospital staff toward working with these patients.  Caught between what they have been taught represents “good” professional treatment and their own personal (often equated with “bad”) reactions provoked by the tactics and behaviours of patients, staff members eventually become incapacitated in their treatment efforts.  The conflict is between how the staff should treat patients and how they spontaneously want to respond.

It is easy to understand the genesis of this bind.  If the staff accept the view that the mentally ill patient is not responsible for his actions, then it follows that the essentials of any humanitarian treatment approach must always be comprised of love, kindness, acceptance and understand; above all, it is professionally inappropriate to criticise strongly, to react angrily or punish patients for their behaviours, since such behaviour has been caused by factors beyond their control.  On the other hand, day to day experience with these patients invariably arouses in the staff reactions which are diametrically opposed to those which they are expected to feel.

If staff attitudes must under all circumstances be those of patience, helpfulness, love and acceptance, what options do staff members have when they frequently find themselves impatient, helpless, angry and revolted by patients behaviours?  Not only is it difficult for the staff to act persistently one way when they feel another but this same hypocritical façade weakens the therapeutic effectiveness of their efforts.  Despite the loud and clear messages from their adrenals and viscera, staff members are permitted only a very limited response repertoire to the behavioural weapons employed by patients.  The staff members tend to resolve the conflicts of this bind by assuming an observable set of attitudes and behaviours which oftentimes complements those of patients.  We have labelled this characteristic staff reaction the syndrome of “chronic staffrenia”.  The components of this syndrome include apathy, weariness, minimal personal involvement, decreased enthusiasm, lack of emotional investment and markedly decreased expectations for patient rehabilitation.  Staff attitudes are depicted by such statements as “let well enough alone”, or “to hell with it – it just isn’t worth it”.  Staff members increasingly withdraw and engage in perfunctory therapeutic activities which, regardless of their name, at best resemble good custodial care, and they become all too happy to settle for patient co-operator in lieu of patient rehabilitation.  Any program that aims at rehabilitating chronic schizophrenics (in contract to one that merely provides good custodial care) must anticipate this syndrome and take measures to prevent or cope with its development.

Implications for Treatment

Any therapeutic program primarily employing psychosocial techniques for the modification of chronic schizophrenic behaviour must make certain operational assumptions as a basis for effective therapeutic action.  The primary and most important assumption is that the patient is responsible for his actions and can muster up the necessary will power to act sanely and decently if he should choose, or be made to choose to do so.  Given this assumption, certain treatment implications follow.

First, the staff must hold patients accountable for their actions, rewarding appropriate behaviour and punishing inappropriate or deviant behaviour.  One of the problems in such a seemingly simple philosophy is that it runs counter to much current clinical thought.  It is our feeling that today’s dynamically oriented theoreticians have placed the onus of responsibility for the patients behaviour on such scapegoat devils as mother, society, or mythical biochemical abnormalities, rather than on the individual patient himself.  With such convenient whipping boys, where everyone is to blame, nobody is to blame.  If the patient cannot be blamed, then, it follows; he cannot take credit for healthy sane behaviour.  We contend that holding patients responsible for both their good and bad behaviour invests them with human dignity and hope; not holding them responsible is tantamount to pronouncing them hopeless.

Our own simplified view of psychotherapy dictates that the assumption of responsibility by the patient represents a prerequisite for any further constructional behavioural change.  If patients are to be receptive to treatment, their attitude must include four successive components or stages which are as follows:

a. I am responsible for my behaviour;
b. I want to change my behaviour since it dissatisfies me;
c. I need help; and
d. I will co-operate with the help you give me.

These stages not only hold for the rehabilitation of the alcoholic, juvenile delinquent, criminal, the patient with a character disorder and the psychoneurotic patient but for the chronic schizophrenic patient as well.  The major problem with the chronic patient is to get him to move form a position where he denies all responsibility for his behaviour or excuses it under the banner of insanity to the first of these states.  Once this id done a major barrier is crossed.

Since staff members have been commissioned to intervene therapeutically with these patients, the second treatment implication is that the staff must have certain rights consonant with their obligations.  In out current and legitimate concern for the rights of patients, we have overlooked or ignored the rights of those working with them.  What currently obtains in most treatment programs is that the staff members have “the right” to being cursed, threatened, or assaulted by ungrateful patients without being able to punish them for their actions or to vent openly their genuine feelings.  However, we insist that the staff should and do have certain rights, the right to expect gratitude form patients and safely from physical harm to interact honestly with patients, to be creative, and to derive a sense of accomplishment from their work.  These are not idealised luxuries but absolute necessities for treatment staff.  Unless their necessary right are encourages, implemented and insured, we are convinced that no intensive, persistent, and concerted staff treatment effort can occur.  Unless the staff can demand responsible behaviour and respect for their rights from patients, the counter therapeutic tactics of patients will surely and inevitably extinguish any remnants of staff rehabilitative efforts of their behalf.

A third treatment implication is that the staff be genuine with patients.  We propose that the staff not be pressured to hide behind pseudo-humanitarian treatment slogans which decree that love and understanding are the only appropriate responses to all patients behaviours and that anger and even occasional hatred are anti-therapeutic.  There is nothing inherently wrong in admiring and liking the good qualities of patients while, at the same time, disliking and rejecting their undesirable qualities.  If staff members are forced to conform to hackneyed platitudes, their response, at best will consist of perfunctory love, phoney acceptance, misguided kindness or biased understanding.  We believe in most appropriate that the staff be allowed to give patients accurate and honest human feedback concerning the impact and social consequences of their behaviour.  For example, it is unreasonable to insist that the staff adopt inappropriate smiles or act kindly toward patients while brimming with anger.  Our contention is that “love and understanding” are not simply insufficient, but at times are actually incongruous and damaging in response to certain patient behaviours.  The staff should be allowed and encouraged to use a whole relationship: both to be positive, warm and loving when patients behave sanely and well, and also to be angry, rebuking, rejecting and punishing when patients are obnoxious or bad.  Them combination of Pollyanna plus Scrooge represents a more whole, integrated, human response, either along is a travesty.

A fourth implication pertains to the so –called rights and prerogatives of the chronic patient.  From our assumptions it follows that patients not be allowed to become too comfortable or settled in the hospital.  It is imperative that the staff feel free to usurp and confiscate the patients “squatters” rights and convey insistently and persistently to patients that they are not only do not have the right to remain in the hospital, but that the only virgin land available for homesteading lies outside the hospital.

Other treatment implications pertain directly to jamming the various weapons which patients employ.  It makes little sense to continue to treat these patients as perpetual convalescents and invalids by waiting on them and thereby encouraging and reinforcing dependency.  As long as patients can continue to gain all the prerogatives and privileges without effort, there is little incentive for them to change.  As long as their craziness continues to pay off without uncomfortable repercussions or sanctions, we encourage the development and perpetuation of chronicity.

Ethical Issues

In evolving a treatment philosophy for chronic schizophrenics, we have had to grapple with a number of ethical issues, posed by ourselves and respected colleagues, concerning staff attitudes and treatment approaches toward these patients.  Since the direction and development of any treatment program is contingent upon how these issues are resolved, their importance cannot be stressed enough.

One of the immediate ethical issues involves the use of punishment for patients.  Without delving into all aspects of this problem, which would require a separate paper to do full justice to it, we will simply say that this issue is largely artificial or moot, for there are no psychosocial techniques for instituting human behavioural change which do not employ the very potent tools of both reward and punishment.  Even those programs which espouse only benevolent approaches make liberal use of such negative reinforcements as withholding privileges, withdrawing love or approval restraints and seclusion, ECT and drugs for the avowed purpose of “controlling” patient behaviour, but eh rationales offered are often only euphemistic or socially condoned excuses for subtle or blatant punishments.  The issue is not whether punishments should be used; they are and will be – this is simple a fact of all clinical and social life.  The real issue is whether punishments will be administered openly, non-apologetically, and in a consistent, systematic,  goal-oriented manner rather than on a disguised, apologetic, whimsical and haphazard basis.

There are those who fear that once the use of punishment is openly acknowledged and condoned, it might well serve as a vehicle for sadism.  We sympathise with and share this concern; however, the essence of the problem is whether the therapist uses punishment solely for his own gratification or for the patient’s welfare.  Our position is simply that if a therapist is sadistic, he will be ingenious enough to find a vehicle for his sadism in any type of therapeutic approach, even in benign non directive therapies.  Or to put it differently, the beatific smile of the therapist does not guarantee that there are not fangs hidden behind it.

A critical ethical question is to what lengths will be go to implement our treatment goals?  Should the goal be to maintain a chronic schizophrenic comfortable in the hospital or to undertake the more ambitious task of helping him become a relatively whole, occasionally uncomfortable person functioning outside the hospital?  If we choose the latter goal (a formidable task), then, it follows, that certain procedures, which might be considered drastic or extreme, will have to be employed.

It cannot be overemphasized how serious and malignant a problem chronic schizophrenia is.  As the situation now stands, these patients represent serious economic, social, political and psychologic debits not only to society by themselves as well.  Many represent the psychologic equivalents of terminal cancer patients devoid of any prospects of a productive existence.  Therefore, we have to make the operational value choice of either preparing them for a comfortable psychologic demise of using, if necessary, radical procedures which measurable increase their chance for responsible meaningful living.

In any radical procedure there must be a willingness for balance the potential risks against the possible gains.  It is our impression that most professionals working in this area have been reluctant to confront the issue of risk and have chosen instead to play it safe.  One way of playing it safe has been to settle for more modest treatment goals for these patients.  Another way (but a valuable one at that) is to concentrate exclusively on the etiologic and preventative aspects of the problem.  It is riskier, but at least equally important, to engage the problem here and now – that is, if we are not going to let patients psychologically rot in the mental hospitals until we engineer social change or determine the presumed biochemical abnormality underlying this disorder.

The bind we are in, whether we like it or not, is that we must deal with these patients.  In doing so, we have to choose between two options.  We can employ palliative procedures with the risk or keeping patients psychologically moribund or of leading to their psychologic death; or we can try radical psychosocial procedures with the possibility of curing the patient, but the risk of his getting worse.  Should this latter possibility occur, the therapist lays himself open to being labelled anti-therapeutic or destructive; we suspect that one reason many therapist have chosen palliative procedures is not to risk censure form colleagues and to void receiving such labels.  Unfortunately for patients, we have been too bound to the principle of primum non nocere (“first do no harm”), and as a result have been employing a variety of gum drop therapies for a very malignant problem.

Long ago Archimedes stated that if he had a lever long enough and a fulcrum on which to rest it, he could move the earth.  It is our contention that we already have at our disposal some therapeutic levers or techniques for dealing with chronic schizophrenics.  If out goal is the ultimate rehabilitation of these patients, we must begin to search for even more potent and effective levers, which may involve to some degree the use of pain, deprivation, and punishment – all socially sensitive areas in the treatment of patients.  It is not enough simply to theorise about these techniques, we must demonstrate a willingness to use and evaluate them.

A final ethical issue concern the question of whether patients should have the right to opt out of living in normal society.  For those who find life and responsibility too stressful should we provide some haven or retreat in the form of mental hospitals, where they can spend the remainder of their days in relative peace and quiet?  Perhaps the ramifications of this issue could be debated endlessly; we have resolved this issue for ourselves by arbitrarily claiming that just as a person does not have the social or legal right to commit suicide, so too the chronic schizophrenic does not have the right to commit psychologic suicide by giving up or opting out through prolonged hospitalisation.  Again just as when a person attempts suicide, every possible technique or treatment, not mater how drastic, is employed by the physician to aid him, so too, we contend that every possible therapeutic technique even those seemingly drastic should be brought to bear psychosocially to revive the chronic schizophrenic.

Summary

In this age of psychologic understanding, modern clinical theoreticians have emphasised the importance of familial, social and institutional iniquities as largely responsible for the production and maintenance of chronic schizophrenia.  Chronic schizophrenics are usually portrayed as hapless, helpless creatures impotent against the powerful forces which shape their pathology.  Unfortunately, such a view completely overlooks the rather “naïve” possibility that patients themselves become chronic simply because they choose to.

From the clinical experience, we have become convinced that chronic patients are anything but fragile, helpless people.  In fact, they are quite ingenious in employing an array or counter therapeutic weapons or tactics which are highly effective in achieving their goal – namely, continued hospitalisation.  We have described many of these weapons within the body of the article.

One of the major problems in establishing and maintaining an intensive, enthusiastic therapeutic program for patients pertains to the reaction of the hospital staff (the syndrome of “chronic staffrenia”) to the tactics of patients.  Unless this staff reaction can be prevented, it is unlikely that any treatment program will prove effective.

Starting with the assumption that patients must be regarded as responsible for their behaviour, we have presented a number of treatment principles which seem crucial for the treatment and rehabilitation of chronic schizophrenics.  The principles outlines raise a number of serious ethical issues which are also discussed within the article.

Reference:
1. The Code of Chronicity.