Vijendra Kumar S.K, M.A., M.Phil.
Usha Srinath, M.A., D.M.&S.P.
Chief Clinical Psychologist and Psychotherapist
Athma Shakti Vidyalaya
Kumar SK & Srinath U. (2009). Psychosocial Rehabilitation: A Descriptive Case Study of a
Therapeutic Community. International Journal of Psychosocial Rehabilitation. Vol 13(2). 39-48
Athma Shakti Vidyalaya,
No.113, Madhuban Colony,
INDIA-560076. E-mail: firstname.lastname@example.org
I am grateful to Fr. Hank Nunn, Director; Dale Peacock, Psychotherapist and Anando Chattergi, Counselor for their encouragement, support and sharing information. My thanks are due to Mrs Amita Santiago, lecturer in English,
Athma Shakti Vidyalaya, is a therapeutic community, for persons suffering from chronic mental illness like schizophrenia that is based on the philosophy of transactional analysis and Reparenting model of psychotherapy. The present study utilizes the descriptive type of holistic-single case study design to delineate the structure and function of an organization, highlighting the unique approach used in the rehabilitation of the mentally ill, both from the psycho social and socio-cultural perspectives.
Key words: chronic schizophrenia; psychosocial rehabilitation; therapeutic community.
One of the most severe and challenging diseases to deal with in the field of abnormal human behaviour is schizophrenia. Carson & Butcher (1992) define it as: “the schizophrenias are a group of psychotic disorders characterized mainly by gross distortions of reality; withdrawal from social interaction; and disorganization and fragmentation of perception, thought and emotion” (Pp. 428).
The definition is elaborated and described in ICD -10 as: The schizophrenic disorders are characterized in general by fundamental and characteristic distortions of thinking and perception, and by inappropriate or blunted affect. Clear consciousness and intellectual capacity are usually maintained, although certain cognitive deficits may evolve in the course of time. The disturbance involves the most basic functions that give the normal person a feeling of individuality, uniqueness, and self-perception (CDDG, 1992: Pp. 86).
Treatment of schizophrenia has three main components. First, there are medications to relieve symptoms and prevent relapse. Second, education and psychosocial interventions help patients and families cope with the illness and its complications, and help prevent relapse. Third, rehabilitation helps patients reintegrate into the community and regain educational or occupational functioning. The real challenge in the care of people suffering from schizophrenia is the need to organize services that lead seamlessly from early identification to regular treatment and rehabilitation (WHO report, 2001, Pp. 68).
Acute syndrome schizophrenics generally do well with medications and psychosocial interventions. But when patients have poor social adjustment and behavioural defects characteristics of chronic schizophrenia, they require more elaborate after-care programme, which is provided in rehabilitation set-up. Maintenance Drug therapy plays an important part, but the main emphasis is on a programme of rehabilitation tailored to the needs of the individual patient (Gelder et al, 1996).
Therapeutic Community is a tertiary preventive measure to reduce the impact of maladaptive behaviour and making the rehabilitation efforts more from the environmental approach (Carson & Butcher, 1992).
The Therapeutic Community movement originated as Northfield Experiments in North field hospital,
Maxwell Jones (1959) developed these ideas further at the Henderson Hospital and described a Therapeutic community as distinctive among other comparable treatment centers in the way the institution’s total resources, both staff and patients’, are self-consciously pooled in functioning treatment. This implies, above all a change in the usual status of patients in collaboration with the staff, they now become active participants in the therapy of themselves and other patients and in other aspects of the over-all hospital work in contrast to their relatively more passive, recipient role in conventional treatment regimes (Jones, 1973, Pp. 427).
Even though TC’s are extension of hospital and after care centers with more freedom and humanitarian treatment, they differ in their values and treatment process. Kennard (2005) observes therapeutic community as follows:
In one sense TCs can be seen as all about continuous risk assessment and management, where episodes of destructive behaviour or threats of it are regularly discussed, analysed and commented on by staff and clients in the small and large groups. In another sense TCs can be seen as allowing levels of risk that units with seclusion rooms, close observation policies and rapid tranquillisation avoid- at the cost of no one learning anything about changing self-defeating ways of thinking, personal responsibility or concern for the effects on others (Pp. I).
Objectives and philosophy of Athma Shakti Vidyalaya: A therapeutic community
‘Chronic schizophrenia and other severely mentally ill people need an intervention that offers more than mere psychosocial rehabilitation, thus placing an emphasis on community living with a holistic approach’.
It was with this objective that a group of parents and relatives of a few young adults who were having serious mental illnesses came together in 1979 to discuss along with Jacquee, L.Schiff and Fr. Hank Nunn and other renowned therapists the possibilities of opening a therapeutic community in
The members of the community learn to recognize and become aware of unhealthy aspects to their personality through their interactions with other members. There is a continuous emphasis that no matter what their problem is, they are OK. The members are made to feel responsible for the harmonious functioning of the community by helping in keeping it clean, cooking, washing, eating together, respecting one another and on the whole enjoying the process of getting well.
Athma Shakti Vidyalaya (ASV), a residential therapeutic community, is based on the principles of democratic therapeutic communities and theory of Reparenting (Cathexis) model of Transactional Analysis. ASV accommodates a maximum of 24-26 male and female patients or residents called ‘kids’. The majority of population at present is Indian. Generally the community welcomes patients from any part of the world. The population comprises of chronic schizophrenia, chronic bipolar affective disorder and severe personality disorder (predominantly borderline type) patients. Community also treats dual diagnosis cases.
Clinical staff group involves clinical psychologists, psychotherapists, counselors, junior staff, trainees and one consulting psychiatrist, who believes in an eclectic approach of integrating medical and psychosocial model. The community maintains international standard of 2:1 patient-therapist ratio. This ensures the availability of clinical staff to every patient at any required time.
The community provides holistic care to the patients. Holistic mental health believes in total mind-body integration in the healing process rather than just alleviating symptoms of a specific illness.
Athma Shakti Vidyalaya has treated hundreds of mentally ill persons for the past twenty-seven years and in 2003, became member of the ‘Community of Communities’, an international supervising agency in the field of therapeutic communities.
Initial Interview: Getting into organizational culture
The client first meets with the Director and the Clinical Psychologist. The client and those accompanying them are then shown around the house and given information about the treatment methods and process. Clarity of expectations from the patient and the family is noted. A written record about the person’s previous treatment is handed over. The same is discussed in the staff meeting and a decision taken on the basis of interviewer’s observation and treatment record.
Treatment Process: Cultural de-stressing
Athma Shakti Vidyalaya believes in holistic and eclectic approach in dealing with the persons suffering from chronic mental illness. The following is an elaborated description of the treatment process.
Intake Procedure: On the first day one of the residents of the community is allotted to the new client as a ‘buddy’ who will help to explain the routine about the house. Depending on the initial interview the client either comes in as a day patient for 3-5 days as a trial period or is immediately admitted. During the first couple of weeks the client is given time to adjust themselves to the community members and routine. One staff member is responsible to get feedback form staff and residents on a daily basis on the new community member’s potentials, limitations and other behavioural observation.
Clients’ feedback on his/her experience will also be given equal importance.
Welcoming: Welcoming is done on the first day in the traditional way using arathi, offering lemon and garlanding to the patient. Then all the community members introduce themselves to the new client. This is based on Indian tradition and also shows the acceptance of a person as they are, rather than a person with illness or a psychiatric label.
Assessment: This involves a detailed case history of the patient from informants and from patients, if necessary and psychological testing. Some of the tests administered are: Minnesota Multiphasic Personality Inventory (MMPI), Bender-Gestalt Visuo-Motor Test, Sentence Completion Test, Human- Figure Drawing, Rorschach Inkblot Test and Wechsler Memory
Making a Contract with the Community: After the new resident overcome his/her initial adjustment difficulties, the new member makes a verbal contract in which he/she states that he/she will abide by the rules of the community and use the resources of the community to get well and be involved in helping others get well. This is done in the presence of the whole community.
Forming a Mentor Group: Forming a ‘mentor group’ consisting of a few staff members with whom the person thinks he/she would be most comfortable with is the next step. The mentor group will closely work with the person right through his/her treatment in the community.
The mentor group meets to discuss and formulate a treatment plan. This
with a review of the initial expectations set based on the diagnosis
observed behavioural difficulties. Expectations are prioritized and
into smaller short-term goals for a period of 6-8 weeks.
Usually, within the first three months of the patient’s arrival in the community, his/her therapeutic issues come into focus. There are different programmes planned for the resident depending on the problem manifested.
Review and Evaluation: The mentor group will do review and evaluation after 8-12 weeks. The outcome of this meeting will determine the setting of new short-term goals or following up with goals that have not been achieved. Once a year, the residents are assessed on different rating scales to get an overall picture of his/her functioning within the community.
Report: Report of the review is sent to the family and meeting with the family organized if required.
Farewell: A farewell to the resident is organized at the end of his/her treatment in the community. This is a big affair in the community as each residents getting well is celebrated by everybody.
Follow up: The patients keep in touch with the community regularly through telephone, e-mail, letters and visits. They will always remain as members of the ‘larger family’.
Dynamics of treatment: Integrating the fragmented.
In the following pages, the different therapeutic activities are described. Many of them are related to the basic philosophy of the ASV in particular and therapeutic communities in general.
Individual psychotherapy: Every one is unique
Dealing with severe mental illness like schizophrenia requires interventions from many perspectives. Research studies have proved that ‘integration of intensive insight-oriented individual psychotherapy and reality-adaptive supportive psychotherapy depending on the individual patient’s need’ is more effective. The use of pragmatic and broad based psychotherapy that relies at various times on supportive, directive, educational, investigative, and insight-oriented strategies applied flexibly depending on the individual patient’s type of illness. This approach is popularly known as ‘flexible psychotherapy’ (Fenton & Cole, 1999), is very much adapted at ASV as part of individual psychotherapy.
Nurturing: Access to unconditional positive regard nurturing is another important aspect of Reparenting (Schiff, 1969, 70, 75). Parents cannot nurture their children without being physically close to them, hugging them, and holding them. Gowell (1979) writes on Nurturing, “this nurturing is usually in the form of nonsexual physical contact. This means that the individual will ask for, and get experiences of being held in a caretaker’s arm or lap, being massaged, getting his head stroked... ” (Pp. 120-121). Nurturing is the core of ASV’s therapeutic process. It not only provides comfort and care, but also gives the resident an experience of safety, security and being accepted unconditionally.
Not all the staff will give nurturing or non-sexual physical contact to each and every resident. It is based on the rapport and each one’s perception and comfort. If either therapist or resident is not comfortable to give or receive nurturing, then it won’t be given until they resolve their discomfort.
Nurturing or Non-Sexual Physical Contact (NSPC) is nonverbal in nature. Here therapists come from a parental position and nurture the resident, to fulfill his/her regressive needs. Usually it is in the form of physical contact, where the resident puts his or her head on the therapists lap and receives nurturing. Stroking is similar to contact, which includes gentle massaging the patient’s head or back. Holding is similar to mother holding her baby, which makes the distressed or insecure person feels accepted and get the warmth and unconditional positive regard from the therapists.
Groups: Reality met through consensus:
Similar to the objectives of the group therapy in other mental health set ups for schizophrenia (Fenton & Cole, 1999), group therapy here focuses on expressing similar experiences and clarifying one’s doubts. Many conflicts among patients are dealt in groups. T.C.s based on democratic principles, so any issue, which is significant to the either one or more member of the community also brought up in the groups. Again group therapies interact and facilitate other therapeutic process. It is also a forum for concerned confrontation and feedback.
Treatment groups: This group meets once a week. An average group comprises six or seven residents and two-three facilitating therapists. The residents mentor group is where he/she makes his/her short and long range plans regarding his treatment and in the treatment group he/she is consistently guided as to the manner in which he is meeting his goals and these are reviewed after a few months to check whether the goals set by him/her have been reached. He/she thereby progresses to set new goals for the next few months. These goals could range from simple behavioural changes that usually are the case in the earlier stages of treatment to more complex decisions and interactions at a later stage of treatment.
Cognitive retraining group: Persons suffering from schizophrenia may display cognitive impairments, which affect their social skills and functioning. In order to regain and reinforce these mental faculties, retraining is done on a gradual basis, which is similar to other modes of cognitive remediation (Green, 1992; Liberman & Green, 1992; Spaulding, 1989; Spaulding &Sullivan, 1992; Spring & Ravdin, 1992).
Peer group: This is a group designed for clients to freely share information among themselves and discuss problems and disputes that arise and provides a forum for exchange of ideas and feelings on any topic related to the day-to-day functioning of the community. It is also a group for planning the different household responsibilities that members have to undertake for the smooth functioning and cleanliness of the community.
The girls’ group and the boys’ group: All male patients and male members of staff are involved in the boys’ group and the girls’ group is similarly formed. It meets once a week or whenever necessary to discuss matters relevant to sexual issues, identity issues, appropriate ways of relating to members of the opposite sex, appropriate ways of dressing, etc. Therapists offer role modeling and give parenting in areas where information is lacking. The primary focus is to achieve group cohesiveness and provide an arena for members to share their problems, interests and a variety of different concerns they have in common.
SOS group: SOS or Studying of Ourselves is a group, which allows intensive interaction on the prescribed issues from therapists as well as patients. Here even therapists can set goals for themselves and take personal responsibility at an equal level with the residents.
Fun group: This group is for patients whose contact with reality is poor and who tend to withdraw from others. They are kept involved for an hour during which they are expected to pay attention and participate in an indoor game, singing, word building and dancing.
Neuro Lingustic Programming (NLP): Neuro lingustic programming is a newer discipline of helping to people to change their thought process, feelings and behaviour. Dr. John Grinder and Richard Bandler originally founded NLP in 1970s (Bodenhamar & Hall 1999). In the NLP group, the approach towards finding each ones map’s model for different world realities is done by giving a series of questions that would elicit responses relevant to each individual. Once the questions are answered, each one reads their answers in the group. Meta-modeling leads to further clarity and understanding, which the person uses to make new choices to improve themselves.
Yoga and cyclic meditation: Simple yoga exercises and cyclic meditation taught by experts of yoga helps in keeping the residents’ active and focused. Director, Fr. Hank Nunn, conducts yoga and trained residents conduct the cyclic meditation.
There is scope within the treatment process for contact with members of resident’s family. Over the months, through visits and therapy sessions, family members are drawn into the evolving growth of the resident. Some family members also undergo counseling regarding their issues in dealing with the patient. The process is similar to other family therapy approaches (Haley, 1962; Satir, 1967; Minuchin, 1974).
Recreational activities: Games as therapy
ASV provides opportunity for a lot of indoor games for its residents. Some of the games are not only a pastime but also stimulate the cognitive faculties. Residents play amongst themselves and also with staff. All staff and residents birthday will be celebrated in the community. This is a forum for singing and dancing and often ways to express talents. Residents also taking leadership roles like being the Master of Ceremonies at parties. Football and cricket are two out door games where the boys participate with lot of enthusiasm.
Daily routine activities: Can cleaning be therapeutic?
A regular part of each resident’s routine involves cleaning an allotted part of the house and sharing in preparing breakfast for the community. All these activities are taking care by residents in an organized way. It doesn’t mean that all these activities would go smoothly; there are many incidents of conflicts and frictions. But these are resolved either individually or in groups. Some conflicts have to be dealt in community meetings. Such involvement helps to gain a sense of belongingness to the community and need to take care of our surroundings, like how we take care of ourselves. Many chronic schizophrenics, due to their pre morbid personality or illness factor, don’t initiate or concern for either self-hygiene or environmental hygiene. If somebody doesn’t do their jobs, will be confronted either individually or in groups. They also get feedback from peers regarding their passive behaviours.
Journal writing: ‘Registering’ the therapy
Residents are expected to maintain a daily journal. Here they record anything significant in their routine activities, individual therapy, group therapy, any specific incidents like party, welcoming ceremonies, farewell or violent out bursts of peers. The last section is comments by therapists. Journal writing depends on the residents’ level of functioning and there are other structured programes for the more dysfunctional ones.
Structures: Norms for containment
Rules and regulations provide a structure for safety and harmony in the family and society at large. Non-adherence of these structures results in consequences. In the same way the basic foundation of the treatment in the community is the schedule and structure of the daily operation of the community and the daily functioning of the individual patient. They are encouraged by the staff to identify their needs and reassured that the same may be met in healthy ways instead of escalating in order to be noticed or taken care of. “Acting out” at any level is not tolerated and goal oriented consequences are defined with the clear objective of providing safety and security and as a way of encouraging personal responsibility to change.
Structures in the community are both rigid and flexible. It is rigid when it pertains to non-negotiable, core values like violence or stealing and flexible in moving around within the premises.
Within the broader framework of community structures, residents are assessed and they qualify into one of the following:
Responsible person: A member of the community, who can take care of himself and able reach out at times of distress and also able to help other peers and staff in the relevant context. He/ she is also ready to get a job and return to mainstream. Trainee staff also has to become responsible person to take care of dysfunctional people in the community.
Reasonable person: A member of the community, who can take care of himself or able to reach out at times of distress, but not yet in a position to help others to the extent. All the trainee staff join the community as a reasonable person.
Functional person: A member of the community, who is independent in self-care and able to perform simple jobs in the community, but needs lot of support even under minor stress and has difficulty in interpersonal relationships.
Dysfunctional person: A member of the community, who is dysfunctional to the extent that he needed external support in any one or more areas of basic self-care. He/she may also have suicidal, homicidal or running away tendencies, which need to be addressed. They are monitored at close distance and adequate support is given all the time.
Managing client’s violence: Beyond medical model
Restraining: A special method of restraining has been evolved by using mountaineering rope in circumstances when distressed clients turn violent, to help them have control over their impulses to harm themselves and others. In instances of extreme violence and unpredictable behaviour of a client, restrains are used. These are always the final resort to risk management due to violence. At these times, therapists’ significant to the client are allowed to have structured interactions and caring, which is believed to be more helpful than tranquillizers or closed wards.
Time Out: The corner of a room is a place without much external stimulus. A person is asked to face the corner to enable them to settle down from all internal and external agitation and think about what’s distressing them and how they could express and deal with this appropriately in the community.
Middle of the floor: This is the middle of the room where the person is put and expected to think of their inappropriate thinking or behaviour and figure out a way to do the same differently and appropriately.
When clients are in the corner or in the middle of the floor harmful objects like their spectacles, bangles, watch, etc. are taken away to reduce possibilities of causing harm to themselves or others. The very organization of living in a community reduces the risk due to withdrawal and solitude.
Committees within the community: Adding potentials through cooperation.
The community places considerable emphasis and puts in a lot of effort to provide an environment or atmosphere which is as closely akin to that of a family, in which members have a sense of belonging and also are assigned to specific tasks and responsibilities to ensure smooth running of the family.
Members are encouraged to participate and be actively involved in their own therapy but also to contribute towards a variety of matters that range from looking after the household to organizing each ones’ therapy. Each member in the community, both staff and resident is a part of at least one of these committees.Different areas of responsibility are identified and committees formed to oversee the same. Each has a leader and the leaders of each of the committees and the director form the core group.
The committees are as follows:
Therapy Overview Committee: This committee organizes for each resident to have access to all therapeutic interventions that are available in the community. It organizes the entire documentation process and is responsible for organising in-house training in the basic concepts of TA and counseling. The committee also co-ordinates staff to attend external training programs to learn new methods and approaches in psychotherapy.
Structure Review Committee: The main function of this committee is to review general community structures and represent the same in the community meeting.
Household Committee: This committee is in-charge of cleanliness, repairs and general maintenance of the house.
Medical Committee: The responsibility of this committee is to purchase and stock whatever medication is required. This committee also organizes for people to be taken to the hospital whenever needed and to follow up with the prescribed treatment.
Party Committee: This committee organizes all the parties celebrated in the community and to send birthday cards and seasons greetings to all the friends of the community. The committee also organises a variety of recreational activities both in and outside the house. Each committee meets once in three months. Issues arising from these meetings are further discussed in the core group and their decision is followed.
Staff meetings are held between , Monday to Friday in which all staff presence is expected. The agenda for these meetings varies from staff scheduling to discussions on various residents, which requires pooling information and taking a comprehensive decision to work on.
Community level meetings: Forum for open communication
Daily meeting: Once a day, all the community members meet together and group facilitator (usually a senior staff member) gives some questions, which help them to use their critical thinking or be aware of their feelings for that day. It is followed by important announcements for the day and other information regarding issues that need to be known to all the members of the community. Jones (1973) emphasizes on community level meetings and called it as ‘a basic aspect of the therapeutic community’.
community meeting, which is similar to daily meeting. Here, apart from
meeting, review of the previous weeks’ significant events including
movements is done. After reviewing, general businesses of the
are discussed. Then comes personal business, where residents can ask
feedback, if they want to change their any specific structures.
Working in T.Cs is not a smooth flow. It is quite stressful for the staff both physically and emotionally. They need to feel O.K. before helping others in feeling O.K. Meinrath and Roberts (2004) writes about caring for the staff member; The demands of being a good or ideal staff member can take a tremendous toil of a therapeutic community worker. Deprived clients often seem to ask for every thing that they never had as a child and the community seems to demand an incredible dedication from the staff member (Pp.321).The T.C. kind of work life is likely to lead to ‘burn out’ syndrome (Freudenberger, 1975), which reduces the performance of the member and counter productive to the T.C. environment.
perspective is that a
staff member may have his/her own vulnerabilities and inadequacies,
interfere in his/her work, and need to be taken care of. All these
the counselor to under go personal therapy, which occurs in staff
groups. Staff are divided into four groups depending on
level of experience and seniority in the community.
The present case study, based on holistic- single case design (Yin, 1994), describing the structure and function of an organization gives ample evidence on how a therapeutic community can be helpful in the psychosocial and socio-cultural rehabilitation of persons suffering from chronic mental illness like schizophrenia. Not providing quantitative and statistical data in the present article to show the significance of the effectiveness of the community is a serious limitation, thus rendering scope for further study using different design and methodology. Nevertheless, the study took a different perspective; getting into the content and process of an organization, which equally helps in understanding human behaviour and its modalities of change.
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