Copyright © 2009 Southern Development Group, SA. All Rights Reserved.
A Private Non-Profit Agency for the good of all, published in the UK & Honduras
The
International Journal of Psychosocial Rehabilitation
Study
Of A
Therapeutic Community
Vijendra
Kumar S.K, M.A., M.Phil.
Usha Srinath, M.A., D.M.&S.P.
Chief
Clinical Psychologist and Psychotherapist
Athma Shakti Vidyalaya
Citation:
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
Correspondence:
Athma Shakti Vidyalaya,
No.113, Madhuban Colony,
INDIA-560076. E-mail: srinathusha@yahoo.com
Acknowledgements
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,
Abstract
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.
Introduction
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.
Setting:
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.
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
Test.
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.
Mentor
Group
Meetings:
The mentor group meets to discuss and formulate a treatment plan. This
begins
with a review of the initial expectations set based on the diagnosis
and
observed behavioural difficulties. Expectations are prioritized and
broken down
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).
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).
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.
Family
therapy:
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:
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.
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.
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
meeting:
Staff
meetings are held between
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’.
Weekly
meeting: It
is called
community meeting, which is similar to daily meeting. Here, apart from
daily
meeting, review of the previous weeks’ significant events including
visitors’
movements is done. After reviewing, general businesses of the
community
are discussed. Then comes personal business, where residents can ask
for
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.
Another
perspective is that a
staff member may have his/her own vulnerabilities and inadequacies,
which
interfere in his/her work, and need to be taken care of. All these
factors push
the counselor to under go personal therapy, which occurs in staff
therapy
groups.
Conclusion
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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