Int. Disubil. Studies, 9, 129-131.0 Eular Publishers

IRMA V Conference Paper

Rehabilitation of chronic schizophrenics in a developing country

MOHAMMAD RASHID CHAUDHRY

Fountain House, Lahore, Pakistan

Accepredforpublication: June 1987 Correspondence to: Professor M.R. Chaudhry, Project Director, Fountain House, Lahore, Pakistan

Key words Community care - Rehabilitation - Schizophrenia

Summary Mental health services in Pakistan, as in most developing countries, have not advanced beyond elementary level. Considering the popu- lation size, there are few beds in psychiatric wards or hospitals for those in need, and tittle, if any, opportunity for mentally ill individuals to receive aid and assistance in the community. One model which provides a comprehensive array of services for chronic mental patients in the community is known as the ‘Clubhouse’. Since 1971, Fountain House has provided social, vocational, and residential services to chronic schizophrenics in Lahore, based on the concept of mental patients as members of a club receiving self-help through mutual cooperation. Equally basic to the model is the concept of family structure. Based on 14 years of experience, it has been found that the Clubhouse model can be initiated, grow, and thrive in a developing country. Essential to this process has been full involvement of the community. The model can be fully incorporated with adaptations reflecting local conditions and circumstances in other developing countries.

Introduction

Fountain House, Lahore, has the distinction of being a unique project in the developing countries in the challenging areas of psychiatric care and rehabilitation. The original model of psychiatric services associated with Fountain House was developed in the 1950s and 1960s in New York. When Lahore Mental Health Association sought financial and technical assistance from the Department of Health, Educa- tion and Welfare, Washington, USA, for the establishment of a special rehabilitation project for the mentally ill, a col- laborative link was established with Fountain House, New York .

The rehabilitation centre in Lahore was started at the end of 1971 as a half-way house. Very soon, as a result of the exchan e visits between the projects in Lahore and New

the model developed at Fountain House, New York. It was, however, found essential to adapt and modify various com- ponents of the programme to suit special needs of the persons served in Lahore. Over 10 years of close collabora- tion between the two Houses has shown that, in spite of diverse cultural settings, the basic ideology can be intimately shared and preserved.

The fundamental ideology of Fountain House is extremely simple. It believes that most of the suffering of the mentally ill is caused by their isolation from the society. The image of a mentally ill person usually presented in the medical text- books and fiction was that of a person considered unfit for human companionship and, therefore, the society evolved a procedure of confining them behind high walls and locked doors. The basic need of the mentally ill was acquiring back their right of self-respect and personal dignity. All the ser- vices associated with Fountain House stem from this basic concern.

The important components of the Fountain House model are described below: Clubhouse for members

The original Fountain House in New York resulted from concerted efforts in early 1940s by some patients at Rockland State Hospital. Their primary objective was to help each other in getting jobs. They realized that this could be achieved only through propping up each other’s self-confi- dence. They called themselves WANA, an acronym of We

York, t fl e Lahore programme was organized on the lines of

Are Not Alone. Gradually the group grew in strength and was joined by some volunteers. Soon they were able to raise funds to buy a four-storey brownstone on West 47th St, New York, which had a small fountain on its premises. The place was turned into a clubhouse and was named Fountain House. A programme for daytime activities and an evening recreational programme were developed with the help of dedicated professionals.

Fountain House, Lahore, was initially named Halfway House but very soon collaborating links were established with Fountain House, New York, which resulted in identity of views on basic concepts. The label of Halfway House no longer represented the nature of expanding services. It was therefore decided to adopt the name Fountain House in 1973. Since then collaboration between the two houses has become a unique experiment of cross-cultural collaboration in the field of psychiatric care and rehabilitation. Member- ship at Fountain House, New York, is open to anyone with a history of psychiatric treatment. At Lahore the members are selected on the basis of prescribed criteria. One reason for this restriction was the requirement of research. The other more important reason was that, being a residential facility, it could not throw its doors wide open. The criteria at present limit membership mainly to schizophrenics and exclude people who are mentally retarded, physically dis- abled, or drug addicts. The membership status is permanent. Access to services is their right as resident members, day members, night participants, or casual visitors. Change of status is quite frequent.

Pre-vocational day programme

It has been repeatedly emphasized that psychiatric patients returning to the community face extreme difficulties in acquiring jobs. This situation is partly a result of unfavour- able opinions held by employers, but part of the reason is lack of self-confidence by the psychiatric patients them- selves.

It is essential that such persons are provided with an opportunity to test their own ability to handle responsibilities in a pleasant and sympathetic environment. The role of the staff in this programme requires an attitude which tends to eliminate distance between staff and members. In short, the programme is based on members and staff working together

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Iti t . Disahil. Studies, 1987: vol. 9, no.3

towards the goal of purposeful and meaningful living in the community.

The daytime activity of the Club is divided into a number of units according to the number of jobs which need to be done for the upkeep and running of the Clubhouse. The most important of these units are clerical, kitchen, snackbar, washroom, gardening, and maintenance. Manpower that cannot be absorbed in activities associated with maintenance is engaged in other meaningful activities such as flower making, bookbinding, sewing, handicraft, plaster of pans modelling, etc. The main objective of all these activities is to prepare members for taking up jobs of responsibility outside the House by getting used to working with other people.

Transitional employment programme (TEP)

Even after having gone through the prevocational day programme in Fountain House, most of the members are apprehensive about going to work outside the sheltered environment. They fear rejection by employers and unsym- pathetic behaviour by co-workers. They need further support in handling jobs in the competitive world of business and industry with confidence. The TEP has opened new avenues in this difficult area by enlisting the continued help of employers in business and industry in the form of jobs reserved for Fountain House members.

Fountain House, New York, has found it possible to make this arrangement with over 150 business firms for the employment of Fountain House members under TEP. The impressive results of this experiment have encouraged a number of other rehabilitation centres to adopt TEP pro- grammes in the United States. Fountain House, Lahore, however, has the distinction of being the only rehabilitation centre to adopt this approach outside the United States.

It has taken a good deal of effort and public relations to convince the business community that improved mental patients could become useful and productive members of society. In the beginning there was a good deal of resistance. The employment situation in Pakistan is very tight, and even able-bodied persons with sound minds find it difficult to secure jobs. It was, therefore, advisable to request employers for only the entry-level jobs. The nature of the job is then carefully evaluated by social workers, in some cases by doing the jobs themselves. The working day is then divided into two halves and each member on TEP is expected to work only for half of the day.

The greatest success in this area was achieved by contact- ing the Lahore Chamber of Commerce and Industry and, through them, interested employers. The notable success in this regard has been placements with the Rustam and Sohrab Bicycle Factory, which has provided work for a number of Fountain House members. More recently a relationship of this nature has been established with a number of paint shops where the members are used for sorting out various brands and colours. Placement of members in groups has been found to be very satisfactory because of the mutual support by members of each other. Group placement has worked most successfully in plant nurseries.

In spite of this encouraging breakthrough in a difficult and challenging area, it has not been found possible to arrange jobs for all the members considered suitable for the pro- gramme. A plan was therefore worked out for the establish- ment of business enterprises in the community which would be supervised by the Fountain House members. The enter- prise could include snackbars and grocery stores. Funds have been provided by the National Institute of Handicapped

’ Research, USA, for this project, which was launched in 1984. The current plan covers a period of 5 years.

The Fountain House programme does not include the training of members in special skills. The experience so far indicates that most of the members come with only academic

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qualifications, lacking useful skills. Typing classes were started as part of the clerical unit to help with finding jobs. The usefulness of this exercise has remained limited because of the high degree of competition in the field. A simulated workshop has been planned in the Rustam and Sohrab Bicycle Factory where members will be trained for jobs for which there is a definite market. The Fountain House ideology, however, does not support the concept of sheltered workshops.

Fountain House Farm Farooqabad (Chuharkana)

The nature and organization of the Fountain House pro- gramme attracts persons with an urban background. But over 70% of the population of Pakistan resides in rural areas, and it is essential that a rehabilitation programme should be developed to suit the needs of persons coming from an agri- cultural background. The Government of the Punjab was approached for allotment of a piece of agricultural land in the vicinity of Lahore for establishment of an agricultural farm project. A piece of agricultural land of 10 hectares at Chuharkana, about 40 km from Lahore, was allotted to Fountain House in 1982. Construction of residential quarters for members was completed in February 1983, and the project was formally inaugurated in March of that year. Members who live on the farm are engaged in plantation, vegetable growing, crops, and other farming activities in addition to maintenance. Recently fish, poultry, and goat farms were added. These additional projects will not only help to train persons from rural areas for productive activities, but also generate funds to make the rehabilitation services self-supporting.

It is envisaged that the simple nature of the agricultural activity will also be helpful as a form of therapy (agro- therapy) for those members from urban areas who need to be engaged in healthy outdoor work. This has already been tried with some members, and a significant improvement in their physical and mental health was noted.

A research project has been planned to determine the effectiveness of agro-therapy in the most challenging domain of rehabilitation of chronic schizophrenics. This will be a unique experiment in rehabilitation of the mentally ill in a developing country like Pakistan, where majority of the population (about 70%) resides in rural areas.

Music therapy

Music classes are held daily for 1 hour. As elsewhere, music has been found very helpful with withdrawn non-communi- cating schizophrenics, who not only become communicative but actively participate in the music programme.

Religious practices as part of therapy

It is being increasingly realized even in western countries that religious values and practices bring tranquillity and stability to the lives of the people. The mentally ill are no exception to this rule. The first effort towards rehabilitation of the men- tally ill in western countries was called ‘moral education’. N o modem approach in this area could be called complete and comprehensive without incorporating an element of moral values.

Fountain House, Lahore, has made religious instruction and religious practices an integral part of the daily pro- gramme. A mosque has been constructed on the premises, which has made it possible for the members to offer daily prayers together. The mosque is also being used for group activities such as ‘Milad’ and speech contests on religious topics, Occasionally renowned religious leaders are invited to deliver lectures for the enlightenment of members and

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CHAUDHRY: Schizophrenia in a developing country

staff. Tapes of recitations from the Quran by renowned Qaris are also played daily after Zohar Prayers.

The morning programme after breakfast is started by read- ing of verses from the Holy Quran. The services of a Qari have been acquired for this purpose; he spends most of his time with the members to motivate them to offer prayers regularly and lead a clean moral life. It is felt that participa- tion in religious activities has not only helped in strengthen- ing the mental health of members but it has also kept the atmosphere free from the moral and sexual deviations usually associated with living in large groups. Another mosque has been built on the premises of the farm at Chuhar- kana.

New developments

After gaining experience in the field of community rehabilit- ation of the mentally ill spread over 12 years, a number of new schemes have been prepared to strengthen the pro- gramme. The following are some of the plans which are currently in the process of implementation.

APARTMENT SCHEME There is a good deal of pressure on Fountain House because of the increasing number of residential members. There is also a gradual accumulation of long-stay members who either have no families to go back to or have to stay in Lahore because of jobs arranged for them by Fountain House. A separate community housing programme has been designed to encourage the members to live in small groups, either independently or supervised by a member of the staff.

The first apartment under the scheme has been started in a rented house in Sanda Kalan, a thickly populated new locality of Lahore not very far from Fountain House. The site of the new apartment has been chosen with care so that it gives the members a chance to interact with the community around them whilst allowing opportunities to use recreational and other facilities at Fountain House.

SIMULATED WORKSHOP Experience has shown that most of the members of Fountain House needed to acquire some form of skill before they

could be placed in jobs. Opportunities for technical training are very limited outside technical institutions. A scheme for the establishment of a simulated workshop was prepared so that members could be trained under conditions similar to real job situations for placement in guaranteed jobs. Such a workshop could be established either as part of a factory or on Fountain House premises. An arrangement is being made with the Rustam and Sohrab Bicycle Factory at Shahdara for the establishment of such a workshop at that factory.

SMALL BUSINESS ENTERPRISES A large number of members of Fountain House desire either to establish a small business of their own or to help in a family business. In order to give these members a chance to gain experience under supervised conditions, a plan has been worked out to start business enterprises in the community. The running of these enterprises will be entrusted to small groups of members, and their work will be supervised by a member of the staff. The first important step in the area of business enterprises was taken by establishing a canteen near the gate of Fountain House and, therefore, easily accessible to visitors as well as members and staff. The canteen was initially supervised by a member of the staff, but gradually the total responsibility for running this enterprise was handed over to suitable members. It is planned to utilize these trained members to run similar projects in the community. A thrift shop has also been established on the premises for the sale of Fountain House products as well as articles donated to the House.

EVALUATION Periodic follow-up studies have been undertaken in the past to assess the effectiveness of the services of the House. In order to enhance the reliability of these studies and evaluate the cross-cultural validity of the essential components of the clubhouse model, Fountain House, New York, and Foun- tain House, Lahore, were linked by collaborative research. Regular data are being exchanged and the information sent to New York is fed to a computer along with data from a large number of other centres in the USA for analysis in terms of a scheme of categories of adjustment developed at Fountain House, New York.

-- Book Review ‘Where more is meant than meets the ear’

Hearing Impairnient, Auditory Perception and Language Disability. John Bamford and Elaine Saunders. Edward Arnold, London. 290 pp., 33 illus. 114.95. SIBN 0-71314194.

This is the eighth book in an excellent series edited by Jean Cooper and David Crystal which aims to bring together the knowledge and expertise of all disciplines involved in the field of childhood language disability.

The authors undertook to review, precis, and reference the state of current knowledge about language disability resulting from hearing impairment in the pre-lingual child. They have achieved an authoritative and informative text which manages to remain extremely ‘readable’ whilst addressing complex, audiological linguistic, psychological. and physiological issues in depth.

Facets of auditory and speech perception in the adult are reviewed in Chapter 1 and provide a good base upon which to understand their development and that of language in children described in the next two chapters. Chapter 4 succinctly details the anatomical structures and pathways that mediate sound from the pinna to the central nervous

system; classifies hearing disorders accordingly, and summarizes preva- lence and causation for each type. The middle chapters reveal the com- plexity and range of psycho-acoustic deficits that occur, over and above reduced auditory sensitivity in hearing impairment - the variability of the deficits both in seventy and nature in children with similar thresholds of auditory sensitivity and the effects on language. spoken and written, in the context of senson-neural, conductive, and unilateral hearing impairment. The final chapter reviews the question of disorders of central auditory perception not associated with peripheral hearing deficit.

The content of each chapter has been thoroughly researched and digested so that the facts are presented and argued in logical sequence in clear descriptive prose. Extensive references are provided at the end of each chapter.

Research scientists, as well as clinical professionals working in the field of language disability, should find this book of great value to them in terms of understanding of the issues involved, of the potential contri- bution of other disciplines to their field, and as a reference source.

P.M. SONKSEN

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