Assisted living within the Therapeutic community in the community ©
Free non-profit counselling centre for psychotherapy e.V. Member of the DPWV
Andreas von Wallenberg Pachaly – Düsseldorf
Table of contents:
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Summary of the
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The Model
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the carrier
1.1 Employees
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the organisation – external structures
2.1 Location and building structures
2.2 Tenancy agreement
2.3 Care contract
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the diagnoses
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admission to the therapeutic community
4.1 Admission requirements
4.2 Perspective group
5 Theoretical Background: The Concept
5.1 The five pillars of the therapeutic community in the community
5.2 The Life Network Group as a System Group
5.3 Type and scope of support
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psychological background: the milieu
6.1 Working with the environment
6.2 Milieu Therapeutic Action Days
6.3 The milieu therapy weekend
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the organisation: internal structures
7.1 The role of the social worker
7.2 The role of supervision
7.3 The importance of work
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leaving the therapeutic community
8.1 Application group
8.2 Aftercare
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relisability by available means
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theory formation and further development
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Final evaluation of the model
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performance levels that are qualitatively improved or economically relieved
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what is innovative?
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evaluability
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summary evaluation
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literature
Berliner Allee 32 – 40213 Düsseldorf, Germany
Phone: 0211/ 88 000 99 – Fax: 0211 / 88 00 97
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summary
The Freie gemeinnützige Beratungsstelle für Psychotherapie e.V. (Free non-profit counselling centre for psychotherapy) looks after four flat-sharing communities with 30 places. The project of assisted living was made possible 10 years ago by the Landschaftsverband Rheinland. A particular concern of the association is not only to relocate mentally ill people from psychiatric institutions to the community, but also to combine this with an increase in qualified rehabilitation and therapy possibilities for those affected. This is the only way for the patient to integrate socially and psychologically into the community. In order to achieve this, we have developed an equivalent model for the outpatient area of assisted living – the Therapeutic Community in the community – based on the Therapeutic Community as it is already known in the inpatient area. Within this framework we try to promote and challenge the healthy parts of the patient in the best possible way and consciously use the constructive forces of the communal group life in the flat-sharing community in order to facilitate the further development of the individual resident. He is helped to work through his deficient and conflicted parts through appropriate psychotherapy, to structure his daily routine in a sufficiently demanding way and we try to restructure his life field into a healing life network group.
History of the
The Freie gemeinnützige Beratungsstelle für Psychotherapie e. V. (Free non-profit counselling centre for psychotherapy) established its first residential community for mentally ill people in 1989, initially with 3 residents. Today we care for 30 mentally ill women and men in a total of 4 flat-sharing communities.
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Disease patterns include massive anxiety, depression, manic-depressive reactions, borderline syndrome, schizophrenia and psychosis. Addictions are excluded. Most of the residents have been in psychiatric hospitals several times and have a correspondingly high dosage of psychotropic drugs when they move into the shared flat. Some of the patients manage to do without it completely in the course of their WG time, others can significantly reduce the dose. The same applies to the number and duration of hospital stays.
Theoretical Background: Concept
For this to be possible, a high level of social energy is required, as generated by the so-called therapeutic community. We understand this as a life-work-learn-community, in which a culture of mutual sympathy, but also regular confrontation with the problems and needs of the individual is promoted. The model is already known in the stationary sector. What is new, however, is that in the WGs we supervise, for the first time an attempt is made to realize the idea of the Therapeutic Community in the ambulatory field: The therapeutic community in the community.
The model is supported by five columns:
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Compulsory participation in two weekly group meetings of the
individual WGs
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fortnightly participation in the large group of all the people we care for
flat-sharing communities
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structured daily routine for each resident, no “hanging around
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to promote participation in an indexed study of the patient in question
psychotherapy
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networking of the patient’s living environment into a life network group
Life in a supervised shared flat is limited to three years and can be extended to a maximum of five years if necessary. In the meantime, the first former residents either live alone in their own apartment, together with a partner or in a free shared flat.
Psychological background
To the life in a cared for flat-sharing community belongs the fact that all inhabitants resurrect its original-conflict and stage the same difficulties with its co-inhabitants in always-same patterns. In the group sessions, the patients learn to talk about exactly these problems. In the process, both interpersonal and organisational concerns are taken into account.
In contrast to other countries from the Anglo-Saxon and Scandinavian area, the knowledge that psychosis and schizophrenia sufferers can also be significantly helped by qualified psychosis psychotherapy is insufficiently widespread in Germany. Instead, it is often recommended to take psychotropic drugs only for the rest of one’s life, which, if not embedded in psychotherapeutic accompaniment and discussion, threatens to continuously undermine the patient’s self-confidence, as their self-healing powers are neither awakened nor supported.
Characteristics of assisted living
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study the group as a community and as a life-work-learning institution.
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benefit of the therapeutic potential of the group, the large group and the life network group.
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promoting a group culture of continuous demand.
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to use group dynamic and psychodynamic knowledge as a possible approach to understand the current group situation and the dynamics of the individual patient in the mirror of the group.
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bringing together the different split and fragmented experiences that the patient has in different areas such as living in the WG, work, psychotherapy.
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to constantly strive for clear boundaries regarding time, place and roles as prerequisites for the process of integration.
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enabling fundamental structural personality changes through the integrated use of qualified borderline or psychotic psychotherapy in so-called psychiatric patients suffering from schizophrenia, psychosis or severe borderline conditions.
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integrative group concept: deliberate bringing together of less severely and severely ill patients of different diagnostic categories into a group (heterogeneous group composition).
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promoting the healthy parts of the patient, demanding his emotional growth and at the same time counteracting malignant regression.
The objectives of our care concept can be summarized as follows:
– Independent household management, self-sufficiency, self-financing of rent and subsistence (no nursing rate)
– Structuring and shaping the daily routine, promotion of differentiated leisure activities
– Psychological stabilisation through group or individual therapy, development and promotion of the ego functions, treatment of life-history traumas
– withdrawal or reduction of psychotropic drugs, reduction in the number and duration of psychiatric hospital stays
– Development of social competence (self-confidence, conflict and relationship skills)
– the ability to argue, the ability to separate oneself from others and an interest in continuing to develop after living in the assisted living community
– To promote the ability to make lasting external contacts, work/employment/training, as well as the ability to get support when difficulties arise.
Self-confidence in dealing with institutions such as authorities, savings banks, etc.
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the carrier
The responsible body of the flat-sharing communities is the “Freie gemeinnützige Beratungsstelle für Psychotherapie e.V.”, member of the German Parity Welfare Association.
The association was founded in 1986 on the private initiative of 7 members working in the medical-therapeutic field. The aim should be a counselling centre that is open to all fellow citizens who would like to be advised about the possibilities of psychotherapy or seek help in acute crisis situations. It is particularly important to reach the population strata, which traditionally have very deep-seated fears of contact with psychotherapy.
Extension of the scope of tasks:
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since 1989 we have tried to make an active contribution to the improvement of outpatient, community-based care for mentally ill people through the area of assisted living.
2.1 Employees
Since November 1996 we have been entitled to three social workers and pedagogues, who are staffed with one social pedagogue and two social pedagogues, for the construction and care of 4 flat-sharing communities for 30 residents. These employees have knowledge and professional experience in the field of psychosocial work, psychotherapy and group work. The residents have the right to be heard when new full-time employees are hired. There are 3.5 hours per week available for supervision under professional supervision.
The work will continue to be supported in terms of content and organisation by a community service worker, 6 volunteers (including 3 trained psychoanalysts and family therapists), some former residents of the flat-sharing communities and a volunteer in the field of public relations.
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the organisation – external structures
3.1 Location and structural structure of the flat-sharing communities
We have rented living space in two large flats in the centre of Düsseldorf and two large single-family houses on the outskirts of the city with good transport connections. Each resident has his or her own room. In addition, all apartments have a common room, a kitchen-living room, at least two bathrooms and separate toilets. One apartment is equipped with a large terrace, to the family house belongs a garden.
3.2 Tenancy agreement
The living space of the flat-sharing communities is rented by the counselling centre for psychotherapy. Each resident receives a contract of use. The current rental costs are borne by the residents themselves.
3.3 Care contract
The care contract includes the goal of care and the care framework such as: Home service meeting, group dynamic meeting, large group, individual care, day job, pychotherapy, specialist medical care, release from the obligation of secrecy towards the treating doctors and psychologists, right of co-determination with the admission of flatmates, accessibility of the living space, responsibility for the furniture in the common rooms, duration of the care relationship / periods of notice.
Violations of the rules lead in serious cases to a warning and in extreme cases to dismissal.
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the diagnoses
The diagnoses of our patients range from extreme anxiety and severe borderline conditions to psychotic, schizophrenic and manic-depressive reactions. Applicants with a primary addiction problem are excluded from admission. The majority of patients have already been hospitalized once or several times in psychiatric treatment. Less than one-fifth have participated only in outpatient psychotherapy without achieving satisfactory results. At the time of admission, over three quarters of patients take psychiatric drugs. Before we admit a patient to one of our residential groups, we get in touch with the treating physicians, psychotherapists or clinics, try to make a diagnosis according to ICD 10, DSMIV and, as far as possible, a psychodynamically formulated understanding of the disease.
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admission to the therapeutic community
5.1 Admission requirements
The main criteria for admission are:
– the willingness to cooperate with the carers, the keeping of obligations as well as the acceptance of the care contract
– the willingness to participate in a day-structuring measure appropriate to the time in question, such as work or part-time employment, sheltered work, further training measures
– the willingness to start appropriate psychotherapy
– the willingness, if initially still necessary, to regularly attend treatment appointments with a resident psychiatrist and to adhere to the medication
– sufficient stability to be able to spend nights and weekends without supervision
– an interest in the community of the residential group and a willingness to engage in life in the residential group over a period of at least three years and to learn from living together
5.2 Perspective group
Interested patients are first offered a preliminary talk. They then have to participate in the so-called perspective group for a few weeks to months. In this group they are taught our concept of assisted living on the one hand, and on the other hand they have the opportunity to become clearer about their motivation. In order to support them, the perspective group is co-led by a former resident of the flat-sharing communities. Seriously interested participants of the perspective group are also offered the opportunity to visit individual flat-sharing communities in order to get to know the residents. In this process of getting to know each other both can exchange their experiences and actively deal with their fears and expectations.
In this phase it is also necessary for our employees to work closely with the institutions that have so far looked after them, such as dormitories, social services, psychiatric clinics, etc., in order to prepare the future residents for the living conditions in the shared flat, which are characterised by greater insecurity and openness. As soon as it has been established that a place for living and care will become available, we will give a binding commitment to one of the applicants.
The residents of the future residential group have the right to be heard when selecting the new resident.
The mental illness as well as the necessity of outpatient care within the framework of an assisted living community must be certified by the treating specialist. When moving in, usually the future flatmates are helpful. The supervisors help to cope with the associated administrative tasks.
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the concept: theoretical background
6.1 The five pillars of the therapeutic community
Graphics of the model:
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each patient must participate in the two groups of his WG led by us.
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a) A group takes place in the rooms of the WG and deals with the organizational aspect of living together.
(b) The second group shall take place on the premises of the helpdesk. This group, which is led by group dynamics, takes care of the emotional needs of the residents.
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each patient must live according to a fixed daily structure, either structured by work, school, sheltered work or a day clinic, etc…
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every patient must participate in psychotherapy according to his needs in order to work through his traumatizing life story. For schizophrenic or manic patients, this often means making them aware of the possibilities of psychotherapy in the first place and supporting them in contacting qualified psychotherapists.
The fourth pillar is the large group, which meets fortnightly. It has the following participants: all residents of all four flat-sharing communities, the carers,
the members of the board, the trained group analysts and family therapists
This group continuously works on the therapeutic cultural space of the assisted living communities as a therapeutic community. At the same time, it gives a sense of security by encompassing the residents of all the communities and creating the feeling of a large community. The large group is the place where the feeling of a life culture can best be experienced, because the different groups can perceive each other and a common border to people who do not live in the residential groups is clearly defined.
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the life network group consisting of:
the living group of the patient, the staff of our institution, the psychiatrist in their private practices, the independently working individual or group therapist,
the work colleague or employee of his (protected) workplace, family, friends,
in times of an acute crisis in the hospital its therapeutic personnel, the employees
of the landscape association and the local social welfare office
6.2 The Life Network Group as a System Group
Definiton: We understand and conceptualize the Life Network Group as the entire social network of relationships in which the individual patient lives.
Fundamental is the realization that within the Life Network group the same phenomena as in large groups occur, sometimes even more intensively. Large group dynamics and especially dynamics of life network groups tend to be experienced as a threatening, persecuting background. It evokes projections, projective identifications and division in the case of borderline personalities and fragmentation, fusion and autism in schizophrenically structured personalities.
The goal of the influential therapeutic members of a Life Network group is to transform their dynamics into a holding background that promotes tolerance, respect, communication, holding and receiving. On this basis, split and fragmented feelings and personal aspects can become visible, pronounceable and thus workable and ultimately integrable. A feeling of security to become master of one’s own destiny, to become able to survive and to leave behind the catastrophe experienced by the self grows in the patient.
Based on our experience to date, we can say that residents in whom we have succeeded in this integration work have made significant progress, both in an intrapsychic area of subjective well-being and in the area of psychopathology, drug consumption and social reintegration into social working and social life. Even for residents who have often been to the clinic, inpatient stays are drastically reduced. Experience has shown that the duration of hospital stays during acute crises is reduced to one to two weeks.
The importance of the institution
The institutional framework is the Freie gemeinnützige Beratungsstelle für Psychotherapie e.V. (Free non-profit counselling centre for psychotherapy). This umbrella organization is of great importance for patients because institutions can in themselves evoke archaic feelings. Since they are experienced as someone who has the power to structure life, there is at times deep confidence in the perceptions that this institution provides. At the one hand it gives security, but at the other hand it is held responsible for feelings of being completely controlled or even of being swallowed up. The 14-day large group is carried out to process this level.
6.2 Type and scope of support
(a) group work
– The perspective group introduces the future resident to the possibilities and conditions of assisted living as a therapeutic community in the community.
– In the fortnightly group dynamic session current problems of living together under the guidance of the supervisor are discussed.
– The weekly convened house meeting meets in the living rooms of the respective WG and deals with the regulation of practical and organizational interests of common household management.
– The large group includes all four of our supervised flat-sharing communities and takes place alternately every two weeks in one of the flat-sharing communities.
– The application group takes place three times a week and is obligatory for all residents without a structured daily routine, without work, protected work, training or similar.
(b) individual work
– The core of the professional care work is the development of sustainable relationships between the caregivers and the residents, as well as their accompaniment and support in personal crises. This is guaranteed by the targeted contacting of the supervising social workers. Furthermore, there is the possibility of discussing current problems of a personal and everyday nature, work questions, job ideas, search for a therapy place, etc. in individual discussions.
c.) Work with the family
– In the case of residents who are still in an intensive, often very problematic relationship with their relatives, individual and family discussions are held with the parents as required. The prerequisite is the consent of the respective resident.
The centre of psychological and social integration lies in the life group of each community. It provides the necessary social energy to bring about profound and lasting personality structure changes.
Our principle of the care work is to promote and demand the greatest possible independence of the residents as well as the self-determination of the individual residents, without delegating the responsibility for the entire development process to the residents.
The aim of the care is to establish stable and sustainable relationships between the residents, so that the previously unconsciously effective destructive relationship patterns can disappear and new, more satisfying relationship patterns can be lived. Conflict management takes place, which becomes possible because traumatic deficits are tolerated and borne until the underlying traumatic experiences and conflictual feelings can be perceived and understood.
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psychological background: the milieu
7.1 Working with the environment
The milieu of the flat-sharing communities as a place of diverse transmission possibilities as well as the work with the milieu are at the centre of the process of dealing with the external reality and the inner psychological reality of the inhabitant and thus have a very high value in assisted living.
The perception and discussion of how the individual residents constructively or destructively design their living space, e.g. how they furnish their rooms, treat the common rooms, spend their leisure time, enter into relationships with people and animals, is important in so far as it reflects the way the affected person deals with themselves. Caregivers and roommates can help the individual to understand the inner-psychological significance of the external event and to relate it to his life story. You can support him in perceiving and reflecting on his positive and creative, but also deficient or even destructive aspects. Through this constructive confrontation with his difficulties in coping with reality, the individual inhabitant can learn to cope with them. Through the support of its positive parts, experiences of success become possible, which bring about a strengthening of the ego. By dealing with destructive behaviour and lifestyle, deficits as a result of conflicts and unbearable feelings, in reaction to traumas suffered, become resolvable.
7.2 Milieu Therapeutic Action Days
In the context of milieu-therapeutic action days, fallow skills are promoted in real practice, e.g. by working together in the home. The carers give the group and individual residents the emotional support and, in individual cases, concrete help to try out and accomplish things which they would otherwise not dare to do, because they are trapped in an encrusted negative attitude which makes everything they tackle appear doomed to failure. To counter this negativism with something positive is an ongoing task at the individual and group levels.
Our experience is that, on the one hand, there is a rather regression-promoting inpatient environment which infantilizes the patient in the long term and, on the other hand, there is an insufficiently supportive situation of outpatient, exclusively medication-based care. In contrast, the protective, but at the same time demanding environment of the assisted living community as a therapeutic community in the community offers many residents a real opportunity for development.
7.3 The milieu therapy weekend
The annual milieu therapy weekend is also held with the aim of giving as many residents of a residential group as possible the opportunity to become creatively active during four days of a long weekend, to make themselves present in the group with their own constructive, creative parts. For the residential group as a whole it is also a chance to get closer together and open the way for outsiders into the group.
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the organisation: internal structures
8.1 The role of the social worker
Their most important task is to bring together the different learning fields of the patient and to help him integrate his split and fragmented experiences.
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they support the residential group in creating an atmosphere of mutual compassion and curiosity.
3) The social worker must check the reality for the patient and support him temporarily in coping with reality.
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to understand the role, importance and scenic significance of the entire residential group for the patient. He must understand the extent to which the latter is staging his infantile traumatic primary group situation, or his basic conflict, again, which aspects he is reviving in the attempt familiar to him (the patient) to cope with the reality of communal life in the living group.
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he tries to clarify what the institution of the counselling centre means for the patient as the supporting association of the flat-sharing communities.
6) The social worker must understand the transfer of the patient to himself, which is often very intense and of great importance to the patient.
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the social worker almost always has to assume maternal or paternal functions, because only then can he succeed in affectively supporting the patient in his growth.
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it is particularly important to make the patient aware that he has deep-rooted, unresolved psychological problems and/or deficits in his personality structure.
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developing a vision with the patient to develop.
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continuous exchange of the social worker with the various people who work with the assisted person.
8.2 The role of supervision
Patients tend to revive and stage their infantile primary group dynamics due to the need for repetition, making the caregiver a target of entanglement and transmission. Supervision is important to help the therapeutic community workers:
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to find oneself and to stay with oneself in the midst of the interpersonal and group dynamic forces of entanglement to which one is exposed
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to become able to endure the feelings of countertransference without succumbing to the feeling of becoming a patient’s puppet
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to clarify how the individual patient restores and stages his primary group dynamics or individual aspects thereof within the group matrix of the flat-sharing community, and which special roles or personality traits he ascribes to individual other residents
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to understand conflicts within the team as a counter-transference to splitting and fragmentation occurring within the patient group
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enable therapeutic teams from other institutions to visit our institution. This promotes professional exchange and has the effect of an institutional supervision.
The continuous supervision work is carried out in two weekly supervision groups in which all full-time employees participate. A large team conference is held every fortnight, attended by all employees, the Executive Board and volunteers.
8.3 The importance of work
As part of the process of social (re)integration, the success of outpatient care always depends on the professional and social integration of the person to be cared for. Aware of this conditionality, work, training or meaningful employment opportunities are of particular importance to the residents. They open the way back into society for him, become a source of constructive self-affirmation and represent socially measurable progress. Often this area of life is also a springboard for further external contacts. Promoting this is particularly important in the second half of the care period, where it is important to help individuals structure their lives after the care phase. Work is associated with a gain in autonomy and enables the patient to set out for an external and internal independence.
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leaving the therapeutic community
9.1 Application group
Three times a week (Mondays, Wednesdays and Fridays) at 8:30 a.m. there will be an application group. It is obligatory for all residents who do not yet have a structured daily routine. Together, advertisements are read in the daily newspapers, letters of application are drawn up, application deadlines are agreed, fears of applications are reduced through role plays, perspectives and visions are worked out for the individual participants. If necessary, contact is also made with the individual companies and workshops, opportunities for internships and taster internships are negotiated, contact is maintained with the employment office and the employment consultants, opportunities for rehabilitation and reintegration measures are explored. The main principle of the application group is that the individual members, with the support of the group, take as much as possible into their own hands and the employees only intervene if this cannot be done by the group.
9.2 Aftercare
In most cases, the need for aftercare of the residents is not necessary because almost all former residents continue their psychotherapy beyond the period of the assisted living. This means that they retain one or more important reference persons in the separation situation. At the same time, many residents take advantage of the opportunity to visit their former residential group even more often and to cultivate friendships with individual former flatmates.
In the critical phase of detachment and emotional separation, assistance is needed in outward orientation and in dealing with emerging changes with regard to the self-structuring of the daily routine or professional work. Individual residents who have to cut their cord for a longer period of time after moving out of their residential group and need the security of the care team can be individually cared for for a longer period of time (up to six months) while they are already living in their own home.
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feasibility through existing resources
The model has been continuously realized and developed since 1989. A first catamnestic study (Hafers, A. 1995) has shown that the success rate is 80% higher compared to conventional treatments.
The model is currently realized by two columns:
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assisted living in accordance with the guidelines of the Landschaftsverband Nordrhein with a care key of 12 residents and a social pedagogue/worker and
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through the honorary commitment of psychoanalysts, system analysts and group analysts, who are responsible for conceptual development, supervision by highly trained group and psychotic psychotherapists, large group leadership and work with the family (in four areas): Sharing responsibility, diagnosing acute stress factors, covering support and psychoeducation, relationship improvement).
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the existing resources, both of the full-time and honorary employees, but above all also of the affected persons and their roommate patients, are optimally used. I.e. the work is consistently on a further development, promotion and demand of the remaining constructive, creative resources of the patron. Through continuous psychotherapy, conflict management and catch-up development takes place in many areas, which exposes new resources to the patient.
At the same time, the group-dynamic and milieu-therapeutic work makes the constructive abilities of the roommate patients mutually usable for each other. It is therefore no coincidence that in the catamnestic examination, when asked what has helped them the most, contact with flatmates is most frequently mentioned.
In this context it is also important to note that the social network of the ex-residents remains important for many and interweaves with their own new circle of friends. At the same time, the integration of ex-residents into the real work, in the perspective group and the board, is an expression of these resources activating and each individual appreciative attitude.
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theory formation and further development
This concept is continuously developed further in a continuous, at least annual professional exchange with members of the:
1st Anglo-Dutch Association for Therapeutic Communities
2nd International Association for Group Psychotherapy
3rd International Society for the Psychological Trearment of the Schizophrenias and other Psychoses
The counselling centre organises an annual symposium in which a forum is created for psychotherapists from the outpatient and inpatient sector and social workers and social pedagogues who work in assisted living facilities or the like, in order to exchange ideas and to be able to further their education in the field of psychotherapy of psychotic illnesses.
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final evaluation of the model
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service levels that are qualitatively improved or economically relieved:
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a) Outpatient medical and psychological care is noticeably expanded through qualitative integration; psychiatric patients who have been stabilized at only a low level through psychopharmacotherapy and fragmented rehabilitation measures, with relatively frequent recurrences, are given the opportunity for real “improvement” at all four service levels discussed by Ciompi. A therapeutic field outside the clinic is opened for them, which offers more than psychopharmacological stabilization at low performance and life level as well as permanent custody in the community.
Patients whose outpatient psychotherapy either always failed or stagnated because the patient’s field of life was too conducive to illness can now be carried out successfully.
By offering a continuous psycho-psychotherapeutic training ingnitive and psychodynamic psychotherapy methods, the competence to treat people with these clinical pictures is improved with medical and psychological psychotherapists.
(b) Inpatient psychiatric treatment may be limited to crisis interventions, as continuity of care and treatment is ensured after discharge. The contact to the patient is maintained by the caregivers as well as the residents during the inpatient stay, so that continuity with a focus on the outpatient area is maintained.
The disadvantages of the US managed care system, in which the stationary
hospital care is limited to 3-4 days, even in the case of acute psychotic reactions, but the patient is then released back into his old environment, thus promoting a rotary psychiatric ward, is avoided while at the same time saving costs.
Sectoral psychiatry, as an attempt to ensure long-term care, is also much more expensive, as the focus here is on expensive inpatient psychiatry.
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c) Integration of the social welfare system: As a decisive cost-causing factor we assess the large fragmentation and the insufficient coordination and integration of the various “helpers”. The inadequate processing of fragmentation and cleavage processes maintains the disease process by continuously strengthening the individual psychological and group dynamic defence formation.
The integrative coordination of all rehabilitation measures and the psychodynamic understanding of the splitting and fragmentation processes staged by the patient enable the individual patient to further develop his interpersonal relationship skills, which form the basis for all vocational rehabilitation. There will be considerable savings for pension providers, social assistance (municipalities) and unemployment benefits (federal government).
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what is innovative?
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(a) enabling improved integration and a lasting, long-term therapeutic and care relationship.
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b) the integration of therapy, rehabilitation measures and assisted living as a school of life (therapeutic community in the sense of Bettelheim’s school of life) is achieved. Ultimately, the patient has the chance to develop this ability identificatively himself.
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c) Through an integrating, intelligent communication exchange, which is trained psychodynamically and group-dynamically, a further development of the personality of the individual is promoted and a stagnation or a step backwards and a personality structure decay is prevented (hospitalism does not only occur in bad clinics, but also on an outpatient basis, if no sufficiently containing and growth-promoting environment is created).
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d) The resources of the Pat. are optimally challenged and promoted on the four axes described by Ciompi: self-responsible living, meaningful activity and paid work, structured and satisfying private life, as little as possible long-term need for care.
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e) Supervision and process management are dovetailed and the life network of the patient is braided, expanded, integrated, challenged and promoted. The aim is for the patient to become increasingly capable of structuring and organizing his own life network.
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f) Rehabilitation is taken seriously. Work is carried out on the psychological structures and conflict resolution takes place: The traumatisation caused by the disease and by traumatisations that support, trigger or make possible the disease process are treated psychotherapeutically. This not only leads to greater “compliance”, but also to a better one, as significantly lower doses of psychotropic drugs become necessary and in some cases can be dispensed with altogether.
In addition to a catching-up development of development deficits, a detection of remaining, buried and undiscovered resources takes place. Together with the living group, team and large group, a vision is developed for the individual patient resident.
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evaluability
Quality assurance takes place through continuous supervision (process quality) and through
Success control.
At the same time, this model can be evaluated relatively easily:
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a) on Ciompis social dimensions and by
(b) psychodiagnostic snapshots taken before, after and three years later and by
(c) the costs saved in the areas of hospitalisation, maintenance and other medical expenses.
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summary assessment
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this model seems to us to be relevant from a health economic point of view in that
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a) hospital stays are reduced
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b) stagnating outpatient psychotherapies can be carried out more effectively and promisingly,
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c) fragmented rehabilitation measures are not wasted, as the necessary conflict and deficit management that accompany them do not fail to materialise and thus do not achieve any success.
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d) psychiatric patients (diagnosed as schizophrenic, psychotic, manic-depressive) do not have to become permanent cases with gradual personality loss in the community.
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immediate feasibility
results from the integration of existing resources and their further development:
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a) Qualified supervision by highly trained group and psychotic psychotherapists
(aa) further training of social workers, social educators and established psychotherapists shall be provided by:
– institute supervision
– Regional continuing education in a supervision and continuing education group
– annual Symposia
– supra-regional through further training in psychosis and schizophrenia psychotherapy
b)an adequate personnel key (1:6)
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c) a continuous commitment to further training and therapeutic self-awareness for all employees.