Fountain House

Creating Community in Mental Health Practice

Alan Doyle, Julius Lanoil, Kenneth Dudek

• Publisher: Columbia University Press
• Year: 2013
• ISBN:
  9780231535991
• Topic: Psicologia
• Subtopic: Consulenza psicoterapeutica

Often people with mental illness feel alone in society, with no place to go and little hope. Their isolation can be further perpetuated through typical approaches to treatment, such as case management and psychotherapy.

Since 1948, the Fountain House "working community" has worked to address the isolation and social stigmatization faced by people with mental illness. This volume describes in detail its evidence-based, cost-effective, and replicable model, which produces substantive outcomes in employment, schooling, housing, and general wellness. Through an emphasis on personal choice, professional and patient collaboration, and, most important, "the need to be needed," Fountain House demonstrates that people with serious mental illness can not only live but also contribute and thrive in society.

The authors also explore the evolution of Fountain House practice, which is grounded in social work and psychiatry and informs current strength-based and recovery methodologies. Its inherent humanity, social inclusivity, message of personal empowerment, and innovation—a unique approach on behalf of people suffering from mental illness—have led to the paradigm's worldwide adoption.

PART I

Working Community

John Henderson Beard

1

INSIGHTS FROM ACTIVITY GROUP THERAPY

Moderate work and regular exercise restored him, in short time, to the full enjoyment of his intellectual faculties.

—PHILIPPE PINEL, A TREATISE ON INSANITY

From 1950 to 1951, John Beard worked in Ward N-206 of the Wayne County General Hospital. The hospital was known locally as Eloise, as it was located in the Detroit suburb of the same name. The ward to which Beard was assigned was populated by about 250 male patients suffering from severe and chronic schizophrenia; no one thought any of them would ever recover. At the time Beard was a second-year graduate student in social work, doing his field placement assignment at the hospital. It was during his time at Eloise that he was introduced to a practice in psychiatric recovery that was to consume his imagination and energies for the remainder of his life.

At Eloise, Beard was wholly taken by the ideas of his supervisor, the young psychiatrist Arthur J. Pearce. Pearce, like other mental health reformers of the time, was appalled by the conditions in which people with mental illness housed in asylums were forced to live. Beard and another colleague, the psychologist Victor Goertzel, learned from Pearce that there was hope for recovery for people suffering from severe mental illness. They had adopted what we would consider today a form of group work practice (Toseland & Rivas, 2011), which they called activity group therapy (AGT). Pearce and his team believed that AGT would restore the social functioning of their patients, a result that in turn offered them the possibility of assimilation back into society upon discharge.

In 1958, the team published an account of their intervention in an article titled “The Effectiveness of Activity Group Therapy with Chronically Regressed Adult Schizophrenics” (Beard, Goertzel, & Pearce, 1958). The article laid out the assumptions that guided their intervention and the strategies that they found effective. Clearly, the authors were energized by the successes that their approach had achieved with the patients on Ward N-206. They asserted that a reality-based, task-group methodology proved to be an effective treatment for even the most withdrawn patients suffering from mental illness. For Beard, however, working at Eloise was a seismic event. The insights he acquired from AGT went far beyond the immediate successes in social reintegration with a small group of patients residing in Eloise. He was to apply a series of tenets he gleaned from AGT for the remainder of his career. Thus AGT was the seed from which Fountain House was later to emerge on West 47th Street in New York City, and that in turn germinated into hundreds of clubhouses all over the world.

AGT Treatment Design

The AGT team was not concerned with issues that normally consumed medical staff, such as differentiating the various illnesses (namely, depression, schizophrenia, psychosis, delusions), identifying their symptoms, or speculating on their etiology. They believed that much of the suffering experienced by patients with mental illnesses was the result of their isolation in society. Schizophrenia, in the team’s understanding, thwarted recovery by condemning patients to a life of loneliness. The case histories of their patients, like the case histories of most people suffering from severe mental illness, clearly illustrated the devastating impact of psychotic behavior upon social relationships. Complications resulting from the patients’ illnesses spilled over into the social fabric of their lives, in many cases ripping it apart. Estranged from family, unable to make friends, and besieged by the loss of jobs, failure in school, and ultimately homelessness, those suffering from mental illness succumbed to withdrawal, isolation, and, at times, conflict. Overt psychotic symptomatology, therefore, was not the only problem that such patients faced. If recovery was to take place, the team members reasoned, attention had to be paid to the destructive impact the illness had on the relational ties of the individuals and the social isolation that resulted. The team therefore expanded their notion of mental illness to include the breakdown in social relationships and defined the problem they would focus upon in treating individuals with severe mental illness in terms of isolation and the loss of the functional capacities of the individual to manage interpersonal relationships in ordinary living situations. They referred to the problem as “relationship failure” (p. 124).

At the same time, they were well aware that during World War II many psychiatric hospitals had depended upon patient labor as a way of remaining in operation. Patients went out into the fields to plant and harvest vegetables for meals, worked in the laundry rooms, and assisted in the kitchens. Likewise, although their patients on Ward N-206 were thought by many to be terminal, and therefore were relegated to remaining imprisoned in empty ward life, some of them demonstrated the ability to leave the wards and engage in ordinary productive activities. In other words, their patients were not wholly consumed by their illnesses. Patients appeared to retain intelligent areas that were fundamentally healthy and resilient. So, despite their illnesses, some of the patients were still capable of successfully engaging in collective endeavors. The observation provoked the assumption that there must be an aspect of the personality that, while latent, remained intact and unaffected by the illness and became activated when the patients left the hospital ward environment. The team referred to this capacity to join in ordinary human activities as “remaining ego strengths” (p. 125).

It was common at that time to describe the human personality in categories derived from Freud—namely, the ego, the id, the superego. In general, the ego was the conscious aspect of the person, which interacted with others and the environment. Intellectual functioning, such as cognition, reasoning, memory, and judgment, was considered to reside within the ego function. Focusing on the ego was pertinent in cases involving people who suffered from schizophrenia, since schizophrenia was essentially considered disruptive of ego functioning. As noted by physicians at the time (Freeman, Cameron, & McGhie, 1958), schizophrenia “is a disturbance of the development and maintenance of adequate ego boundaries which, on the basis of clinical observation, we have come to regard as the central feature of the schizophrenic disease process” (p. 49). With the inability to differentiate between internal thoughts and external realities, the loss of coherent thought patterns, or the erosion of social and other types of cognitive functioning, schizophrenia was considered to be, in effect, the loss of ego functioning of the individual.

On the other hand, when some patients left their hospital wards, they appeared to engage quite readily in activities with others. This observation convinced the team that there was an aspect of the person (i.e., ego functioning) that remained unimpaired by the illness. It prompted the speculation that if they could create an environment on the hospital ward itself that replicated these outside episodes—where the ego capabilities of their patients were not clouded by their mental illnesses—they could stimulate these healthy capacities, to the psychological benefit of their patients. They determined therefore to test the hypothesis—that participation in normal activities improved the condition of the patients—and introduced AGT on the ward.

Another factor also influenced the team’s decision to implement AGT on the ward. They wanted to demonstrate that AGT was a generic approach that could be applied with even the most withdrawn patients, those who rarely, if ever, left the ward. Many programs sponsored in state mental hospitals of the time favored access to opportunities for work and recreation (Cumming and Cumming, 1962). Work, as Sacks (2009) has recently noted, could “normalize and create community, could take patients out of their solipsistic inner worlds” (p. 51). Opportunities for work, however, commonly took patients outside the hospital ward environs and were available only to those who were considered the most socially amenable—leaving the vast majority of patients to remain in gloomy back wards with no such privileges of access to varied and stimulating environments. Pearce and his team, therefore, chose to differentiate their intervention from those of their contemporaries by applying the practice of AGT on the ward. They sought to encourage their patients who remained on the ward to become involved in everyday group activities. If they were successful in engaging these most severely disabled patients in activity groups, they surmised, they could extrapolate their findings and apply them to larger populations of patients suffering from mental illness. Thus AGT was designed as a prototype of action research (box 1.1) (Argyris, Putnam, & Smith, 1985; Lewin, 1946; Stringer, 1999) in task-oriented group therapy. Despite patients’ loss of relationships, the team observed, they retained capacities for normal work when they left the hospital ward. If the team could activate the healthy part of their patients (their ego capacities noted above) and engage individuals in ordinary group processes on the ward, they reasoned, they could rekindle the healthy capacities of the person, which though seemingly overshadowed by ward life still existed. As a result, patients would feel better about themselves. And, hopefully, some would find a way to get on with their lives outside the confines of the hospital. In this way the team introduced activity group therapy as their treatment approach and found that it had a salutary effect on the lives of their patients.

. . .

BOX 1.1.

The methodological design of AGT

Observation: People with mental illness exhibit “ego capacities” outside the hospital environment.

Hypothesis: Participation in task-group activities restores relational bonds.

Treatment: Various task-group activities (AGT) are introduced on hospital ward to draw upon patients’ strengths.

Findings: AGT promotes recovery of people suffering from mental illness.

. . .

AGT also appealed to Pearce and his team because it provided a methodological framework to enlist all the people in the environment—including the hospital attendant staff and even fellow patients—in contributing to the recovery of people with mental illness. AGT created naturally interactive roles among the patients and the ward personnel. Linking the staff and other patients on the ward together in normal human activities (i.e., task-oriented group work), the team believed, would yield meaningful, empowering, and ultimately transformative results. Such a therapeutic application of task-group methodology was directly and profoundly influenced by the emergence of a popular humanistic form of psychiatric practice at the time, milieu therapy.

Resurgence of a Humane Psychiatric Treatment

Milieu therapy began as a reaction to the overcrowding and impoverished conditions that had arisen in the system of state mental institutions where by the mid-twentieth century most people who had been diagnosed as insane or mad were confined. It was accompanied by a resurgence of interest in the precepts of the traitement moral, or moral treatment, of the late eighteenth century. A number of pilot demonstrations (Greenblatt, York, & Brown, 1955) under the generic name of “milieu therapy” were undertaken in hospitals throughout the United States with the clear intention of restoring the enlightened and responsible psychological treatment of patients first promoted by the noted French physician Philippe Pinel (1745–1826).

Pinel’s interest in caring for people who suffered from mental illness developed after the suicide of a close friend. Pinel attributed his friend’s death to the gross mismanagement of the treatment he received. During the eighteenth century most remedies for mentally ill people who were not wealthy involved confinement and harsh treatment. As a citizen of the French Revolution, with its fresh understandings of the rights of mankind and freedom, Pinel believed in the humanity of all people, including those who were considered to be mad. Consequently, he viewed the harsh treatments that were meted out to people with mental illness as unwarranted. He learned from Jean-Baptiste Pussin, the superintendent of Bicêtre Hospital (and former patient¹), that patients were not without the capacity to respond with ordinary motives of hope and reason. Consequently, in his capacity as chief physician at various hospitals in Paris, Pinel advanced a systematic method of care for people afflicted with serious mental illness that favored a sensible approach (i.e., moral) over one of restraints (Pinel, 1806). Specifically, his approach involved close observation of his patients and therapeutic conversations regarding the illusions they verbalized. He also looked for their natural capacities and resilience that could support their improvement.

Pinel’s significance extended beyond his therapeutic methodology, however. He complained, for example, about a hospital environment where

the halls and the passages of the hospital were much confined, and so arranged as to render the cold of winter and the heat of summer equally intolerable and injurious. The chambers were exceedingly small and inconvenient. Baths we had none, though I made repeated applications for them; nor had we extensive liberties for walking, gardening or other exercises. So destitute of accommodations, we found it impossible to class our patients according to the varieties and degrees of their respective maladies. (p. 21)

Pinel wanted all aspects of the patient’s environment organized with a therapeutic intent. He had the chains removed from his patients, and he replaced the dungeons in which they were forced to reside with an asylum where they were free to move around and enjoy the grounds. He advocated an enriched physical environment resembling a more normalized life that included purposeful activities, moderate work, regular exercise, and the selection of attendant staff whose benevolent encouragement would facilitate a therapeutic treatment.

In England Pinel’s teachings regarding the humane treatment of patients suffering from insanity were mirrored by William Tuke, who founded the York Retreat, which applied Quaker teachings to the therapeutic treatment of mental illness (Tuke & Society of Friends, 1813). Like Pinel, Tuke was appalled by the mistreatment of a member of his Quaker community who suffered from mental illness. He was convinced that the conditions of her confinement contributed to her death. He was also influenced by the contemporaneous liberal ideas of John Locke and other political theorists who advocated for universal human dignity and equality. As a result, he determined that the treatment for people suffering from insanity must be offered within a framework that was consistent with our common humanity.

The humane and reasoned approaches of Pinel and Tuke soon found their way to the United States as part of the nineteenth-century innovation in the mental health service system, the asylum.² In the asylum, mental illness was considered treatable. The reformers advocated withdrawing the afflicted individuals from the commotions of ordinary life and locating them where they would be safe from the environment that they believed had caused the illnesses. They enforced a regimen to assist patients in the development of internal means of control so that their behaviors and values mimicked those of people in a normal society. Work was considered the “most efficacious” mode of treatment in this regard (Eddy, 1815, p. 9), as well as close, sociable relationships between the patients and their attending staff. Early adherents of the method required asylums to hire intelligent and sensitive attendants to work with patients, reading to them and talking to them, taking them for walks, and engaging them in other purposeful activities that were designed to distract them from what were considered irrational preoccupations.

A century later, however, most places providing treatment for the insane in the United States had fallen far from the humanistic ideals and medical quality of patient care represented by the enlightened thought of the moral treatment. By the mid-twentieth century, the state mental institutional system, where most people suffering from mental illness were now housed, had abandoned its societal function to restore patients to health and wellness. State mental hospitals had become warehouses of appalling conditions for over half a million people (Grob, 1994), most of whom were considered chronically ill. Their concomitant spiritual, emotional, and intellectual impoverishment only contributed to their deterioration and suffering. State mental institutions, in contrast to their general hospital counterparts, had become overcrowded, understaffed, and repressive institutions that regularly substituted the use of physical restraints for curative methods. Most patient care was virtually left in the hands of untrained custodial staff (Greenblatt, York, & Brown, 1955). So deplorable had conditions become that inadequacies in the number and preparation of staff in these hospitals, whose function it was to minister to sick minds, in contrast to general hospitals ministering to sick bodies, were so marked that “almost no general hospital would consider operation possible under the circumstances” (p. 1). In effect, society had all but determined that severe mental illness was chronic and those who suffered from it had no hope of recovery; consequently, they were not worth the bother.

In response, some in professional psychiatry looked back to the successes of earlier, moral treatment era for a solution. Adherents argued that recovery was possible and sought to change the notion of care for people with mental illness from subsistence maintenance to rehabilitation. They paid particular attention to reviving a relationally supportive social environment in the hospital for a therapeutic purpose—improving the capacity of patients for socialization. The treatment was termed milieu therapy (Rioch & Stanton, 1953). Proponents believed that milieu therapy, as a supportive social environment within the hospital, would have as beneficial an impact upon the patient’s recovery as the dyadic relationship in traditional psychotherapy (Toseland & Siporin, 1986).

To achieve these goals, reformers expanded the treatment of mental illness by a few lone psychiatrists to include anyone who came in contact with patients (the nurses, the attendant staff, and even fellow patients), who constituted their social environment or social milieu, and thus could play a significant role in their recovery. A study of the phenomenon by the Russell Sage Foundation...