The Broader Application of the Model
In a general way, the SEL (Surviving, Existing, Living) model, which I originally developed in my work with people with psychoses (see below), describes phases that all of us may find ourselves in at different points in our lives.
In the Surviving Phase, a person feels acutely distressed, may feel unsafe and/or threatened, and has difficulty in doing even basic daily activities. At those times, it is important to reduce the threats/stressors, re-establish a sense of safety, obtain support, and find ways to reduce the high distress. The goal is to focus primarily on the present, but the past may greatly intrude during such a time of crisis.
In the Existing Phase, a person does only what is needed to get by, and is fearful that adding anything else will result in being overwhelmed. This results in restricting activities, emotions, and involvement/intimacy with others. At such times, strengthening the ability to cope and identifying and addressing stressors that have contributed to being in the Existing Phase are important. Memories of the past may still interfere with a focus on the present and the future, but lessen in intensity with this restricted way of living.
The goal is to work toward being in the Living Phase as much as possible. This is when an individual finds she/he is more fully experiencing life: being more emotionally expressive, seeking greater satisfaction in relationships,and being more involved in work, recreation, and the community. Some "bumps" in life occur, but can be managed with support, and there is a better balance between one's past, present, and future .
The SEL Model
Surviving, Existing, or Living?
The SEL model was originally developed to assist in understanding and helping those diagnosed with schizophrenia. There is burgeoning evidence for psychological and psychosocial interventions for treating psychosis, including for those diagnosed with schizophrenia. However, no single model or intervention has been shown to be most effective. A better approach is to determine what is most effective at what point for a person. The SEL model is a three-phase, conceptual framework that incorporates the key features of severe psychosis, including those diagnosed with schizophrenia, into a single model in order to guide the timing of interventions based on client presentation. Three phases of severe psychosis are outlined in the model: Surviving, Existing, and Living (SEL). The phases are differentiated by where the individual falls on a continuum of eight different factors including the extent of self-definition (self-development), the level of perceived threat (threat appraisal), awareness of others, extent of hallucinations or delusions, awareness of thoughts, logical thinking, emotional awareness, and goal-directed behavior. These factors were chosen based on characteristics generally described in the clinical literature and are assessed dimensionally rather than categorically. The dimensional assessment of multiple, critical factors along a continuum increases precision in determining client status, which then can hone selection of appropriate interventions. In addition, the model offers a comprehensive approach for addressing concerns across a range of domains and difficulties and allows for modification based on fluctuations in client presentation. As a result, there can be a better fit between interventions and client readiness to increase participation, retention, and treatment efficacy.
The continuum provided for each characteristic in this model reflects that individuals experiencing severe psychosis, including those diagnosed with schizophrenia, often fluctuate, such as in intensity of hallucinations or delusions, and in the extent of self, emotional, cognitive, and interpersonal awareness. It also highlights the fact that individuals do not fall neatly into categories of “psychotic” or “not psychotic” or “sick” or “well,” but experience distortions to varying degrees. For example, “voices” or delusions may be perceived to be more or less intrusive and more or less distressing at different times. The continuum in the model accounts for these variations with greater specificity than categorical descriptions.
The three phases represent different levels of progress or regression across the different domains. Briefly stated, the Surviving Phase is the most regressed, acute phase. During the Surviving Phase, a person with severe psychosis may question his/her existence or perceive himself to be under constant threat of harm. As a result, there is a persistent, relentless terror of either not existing or soon perishing. Once personal existence and relative safety are established, the individual moves into an Existing Phase, where there begins some cautious venturing out, psychologically, interpersonally, and physically. Emotional, interpersonal, and intrapersonal experiences may be engaged in very cautiously and in limited ways, which results in a restricted existence. The goal of treatment is to help individuals move into the Living Phase, where it feels safer to engage more fully with the world, to experience a full range of emotions, to try new activities, to introspect in a deeper way, and to participate in closer, more meaningful relationships.
Determining the phase can guide the type and timing of interventions to which the person is most likely to be responsive. For example, in the Surviving phase, the emphasis is on re-establishing a sense of safety, increasing a sense of self, providing support, and promoting stabilization. The focus is primarily on the present. The fundamentals of emotion identification and awareness of thoughts lay the foundation for future interventions. As the individual moves into the Existing Phase, there is an emerging sense of self and of others, and a growing awareness of emotions and of thoughts. Interventions continue to increase the self-definition/self-development and begin psychoeducation, basic skill building, and cognitive-behavioral interventions. Psychotherapy in the Existing Phase facilitates understanding of the individual’s experience and may begin to assist the individual in making meaning of the hallucinations and delusions and increasing awareness and adaptive expression of emotional experiences. Both the present and the future are explored, with reference to the past to the extent tolerated. In the Living Phase, interventions often focus on facilitating and problem-solving as the individual increases his/her experiences interpersonally, vocationally, and recreationally. Traumatic experiences preceding as well as following psychotic experiences also can be further addressed in the Living Phase. Past, present, and future can be navigated with greater tolerance, and the person is more capable of exploring the past as a contributor to the present. Collaboration between medication prescribers and therapists is critical throughout the three phases to allow for coordination of the types of medications needed with the psychosocial interventions being conducted as the individual moves between phases, sometimes advancing and sometimes regressing.