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Disability Due to Mental Illness and Psychosocial Rehabilitation based on

Therapeutic Community Approach

Kamlesh Kumar Sahu1
According to the WHO estimate, 10% of the world population is disabled. Neuro psychiatric
disorders account for nearly one third of the disability in the world. Substantial proportions of
person with mental illness continue to have residual deficits despite best treatment. Majority
of persons with long standing mental illness continue to manifest symptoms or have deficits,
which can be managed in community with proper medical treatment and psychosocial
rehabilitation. The rehabilitation should be tailored to individual needs and aimed to make the
person independent in community. They might not have acquired the necessary skills or lost
the skills due to the illness, which they need to learn/relearn. Rehabilitation should be aimed
at teaching these skills. Each individuals problem is assessed and suitable interventions are
planned. The intervention plans are executed, reviewed and reassessed.
Rehabilitation of disability due to mental illness needs specific modes since psychiatric
disability has its unique features. Therapeutic community approach based model is prepared
to consider a facility offering community based residential and non residential program
providing counselling, social skills training, vocational training, and employment-oriented
rehabilitation seems to be quite effective. This paper will give an appraisal of experiences and
challenge faced by Richmond Fellowship Society (India) which is practicing on therapeutic
community approach since last two decade.
Key words: Schizophrenia, Mental Illness Disability, Vocational Rehabilitation Therapeutic
community approach

India has a population of over one billion with approximately 30-40million persons having
various disabilities. 10-20 / 1000 of the population affected by a serious mental disorder at
any point of time, Neurosis and Psychosomatic disorders 2-3 time high, Mental, Retardation
0.5 - 1% of all children, Alcohol, drug dependence rates on the increase. Disability due to
psychiatric disorders is likely to be due to interaction of multiple causes.
Concept of Disability in Mental Illness
Disability is an important medical and social concept. If a person is unable to perform an
activity, which he is otherwise expected to perform because of his illness that is termed as
disability. Since psychiatric disorders manifest in social context, disability due to them is
generally termed as social disability. WHO defines disability as an inability to participate
or perform at a socially desirable level in such activities as self care, social relationships,
work and situationally appropriate behavior.
Social Disability can manifest in several roles that a person is expected to perform in the
1. Self care: The person may not be able to look after his own care. He may not maintain
good hygiene, may eat erratically, he may not bother about his appearance-he may wear
dirty/torn clothes, may not follow basic manners of a social situation.
2. Interpersonal relationship; He may not be able to make new, meaningful relationships or
maintain the existing ones. His way of relating with people may be distorted or deficient.
3. Family: The person may not be able to keep the atmosphere in the family congenial. He

may be totally withdrawn or hostile towards other family members. He may not take the
financial responsibilities of running a family and on the contrary, may spend a lot of
money unnecessarily. He may not interact actively with others in the family. As a
partner, he may not be able to function as a spouse-he may not fulfill the emotional and
sexual needs of his wife. He may not be able to take major decisions in the family. He
may not interested in the upbringing of his children, and in most of these areas, others
would have taken over the responsibility.
4. Social: The person may not participate in social activities like festivals, marriages and
parties. He may in fact avoid them actively. He may not be aware of the social events
happening around him in his village, state or the country. He may not be aware of the
social events happening around him in his village, state or the country. He may not be
concerned about other citizens rights, and may get into legal problems. He generally
will not be involved in any recreational or religious activities.
5. Occupational: The disability in this field can range from being frequently absent from
work, through poor quality of work to total lack of any occupation.
Unique features of Psychiatric disability
o It is not visible like physical disabilities (e.g. lack of motivation).
o Experienced subjectively (e.g. hearing voices when alone).
o Fluctuates (e.g. disability differs with duration and nature of symptoms).
o Recurrent (e.g. disability reoccurs with fresh episode of illness).
o Affects thinking processes, emotions and behaviour.
o Involves both excesses and deficits (e.g. excesses like overspending, over
talkativeness, over socializing as seen in acute manic episode; deficits like lack of
socializing, decreased personal hygiene).
o Affects the individual as well as the family (e.g. family is burdened emotionally,
financially, and in areas of health, occupation, leisure, social relations).
o The stigma surrounding with mental illness. It contributes to the suffering from
illness in various ways and it may delay appropriate help seeking or terminate
Psychosocial Rehabilitation
Psychosocial Rehabilitation can be defined as a process initiated by a health or a mental
health professional, in collaboration with the patients families and community, and
supported by the policy planner, focused at developing and implementing an individualized
program that seeks to maximize the patients assets and minimize his disabilities in the area
of socio-occupational functioning, centering around the philosophy of mobilizing and
utilizing resources available to the community, with the final objective of mainstreaming the
In the helping professions, the term rehabilitates means to restore to an optimal state of
constructive activity. Of course, what is optimal is relative to the individual. An individuals
optimal level of constructive activity depends on several factors. How well a person functions
depends on how severe his or her illness is at the time, the severity of the persons disability,
the abilities they still possess, the outside supports that are available, and the patients stage
of recovery. Stage of recovery refers to the individuals ability to cope with the disease and
disability and the individuals self-image as a functioning person.
Psychosocial rehabilitation (PSR) refers to efforts to restore persons with psychiatric
disabilities to optimal states of constructive activity. There are a number of definitions of
Psychiatric rehabilitation(Psy.R).Ruth Hughes, the executive director of the International
Association of Psychosocial Rehabilitation Services (IAPSRS),provides an excellent general

definition with which most PSR practiceners can agree: The goals of Psychosocial
rehabilitation is to enable individuals to compensate for, or eliminate the functional deficits,
interpersonal barriers and environmental barriers created by the disability, and to restore
ability for independent living, socialization and effective life management.
Therapeutic Community Approach
Maxwell Jones is known as an originator of Therapeutic Community Approach which is a
Community based approach for psychosocial rehabilitation, began as a post II world war
phenomenon during 1950s with growing interest in social psychiatry the study of the role
of social-psychological and sociological factors in the genesis, maintenance and treatment of
mental disorder. Started as a reaction against the anti-therapeutic effects of mental hospitals
and custodial care, stigma, institutionalization. Therapeutic Community changes in conduct,
attitudes and emotions are monitored and mutually reinforced in the daily regime. Second,
unlike other modalities, TCs offer a systematic approach to achieve its main rehabilitative
objective, which is guided by an explicit perspective on the disorder, the client and recovery.
Therapeutic Communities exists to promote better understanding of human relations.
It was an attempt to establish a democratic system in hospitals where the domination of the
doctors in a traditional hierarchy system was replaced by open communication, information
sharing, decision making by consensus and problem solving and sharing as far as possible
with all patients and staff. The name therapeutic community evolved in these settings. The
expectations from them were: Shoulder Responsibility, Respond to Acceptance and Respect,
Participate in Community life with skilled individual and group support.
What Is Therapeutic Community

Deliberate creation of social group influences

Not a community with therapists but a community with a therapeutic function
Invested in a culture and structure appropriate to the age and needs of the residents
Maintained by staff and residents
Day to day living, interactions and situations are made therapeutic
Residents and staff learn from practical situations from each other
Members confronted with each others strength and limitations
Helps in better feeling of self worth
Provides environment in which integrated personal and social learning takes place
Helps to learn and move towards independence by making greater use of personal and
peer group support

Principles and practices

o Flattening of Hierarchy- addressing by first names to each others event to staffs
o Democratic way of Decision making- each member of the community should share
equally in the exercise of power and decision making.
o Sharing the Responsibility
o Permissiveness - community should be able to tolerate the deviant or abnormal
behavior of its members without suppression, free to express reaction. Objective - to
see and understand the real nature of an individuals problems without restricting their
o Easy accessibility
o Reality Confrontation Behavior is constantly reflected back (Here and now), so they
modify their behavior in order to get a satisfactory response.

o Communalism/ Group Living- All events should be a shared experience, with the
maximum interrelationships, participation and openness.
Therapeutic components
o Homely atmosphere
o Social interaction- is maximized; a complex social system is created.
o Optimum number 15-20
o Sharing rooms-in short term facilities
o Group meetings- activity groups.
o Experimentation with new model of behavior
o Peer confrontations
o Informal atmosphere
o Realistic goal setting
o Residents are encouraged to become less dependent.
o All that happens becomes treatment.
o Community with a therapeutic functions rather than community with therapists.
Interventions aim to enhance skills
a) Basic Living Skills:
Personal hygiene :
1. Brushing teeth
2. Bathing
3. Dressing
4. Grooming (hair & nail)
5. Eating habits
b) Independent Living skills:
A: Basic house keeping:
B: Money Management:
C: Traveling:
D: Leisure time activity
3) Conversational skills:
4) Social skills:
a) Medication management
b) Symptom management
c) Self-care, recreation
d) Basic conversation etc.
Sometimes it focuses on: underlying cognitive deficits, which are responsible for deficits
in social competence.
5) Work behavior skills:
Other intervention strategies:
1. Supportive counselling
2. Activity scheduling
3. Recreation therapy
4. Education of care-givers
5. Vocational training and job placement

Kamlesh Kumar Sahu, M.A. M.Phil. in Psychiatric Social Work

Programme Coordinator
*1912, Panchasayar Road
P.O Panchasayar, Kolkata 700094 (India)
Tel: + 91 033 64170302 | + 91 033 24329339
Fax: + 91 33 24328824 | Mob: 09330178428
E-Mail: Web:
Ex- Lecturer
Richmond Fellowship PG College for Psychosocial Rehabilitation
CHETANA No. 40 1/4, 6th Cross, Vajpeyam Gardens
Ashoknagar, Banashankari, I Stage, Bangalore 560050 (India)
Phone: +91-80-26676134
E-Mail: Website:
*Correspondence address
Paper was persented in National Seminar on Emerging Issues in Disability Studies in
India on 5th and 6th February, 2009; organized by National Centre for Disability
Studies(NCDS),Maidan Garhi, IGNOU, New Delhi 110068 Ph. 011- 29531575, Mobile
09968312328, Fax 011-29535125 Email: