Strength Based Treatment Approach

“Interventions in addition to, and at time instead of the amelioration of their weaknesses and deficiencies are secure in the belief that strengthening the strengths will weaken the weakness” by Positive Psychologist Martin Seligman

John Beard and the other Fountain House program designers were not unaware of the pathological aspects of serious mental illness but chose to focus on or pay attention to the healthy behaviors and personal strengths that people with this illness exhibited. They knew that the experience of mental illness could effect a person’s motivation, cognitive functioning and affective expression, such that some of the skills and abilities on the one hand and the feelings of self confidence and self efficacy on the other, could be negatively impacted. They understood that Life offers us both positive and negative experiences and that both have a formative effect on personality and behavior but that the positive experiences have both a formative and curative effect. They knew that although positive experiences generally have the same impact on all people, the impact of these positive experiences would be greater, because of their rarity, on those most damaged. For many clients ( called members ) their lives before coming to Fountain House involved the devastating effects of stigma and a focus on the illness that many accepted as the primary definition of who they are as human beings. As a result the Fountain House community created a model to offer its members motivating experiences and a focus on their strengths. When this focal point combines with an organizational structure that creates a need for members to help in the operation of the community, empowerment , de-stigmatization, mutual respect and collegial relationships develop. It is this strength based center, the need for member assistance and the collegial relationship that grow as a result, that facilitates the impressive treatment results and the positive emotional tone experienced by most participants and visitors to Fountain House. Many people with serious mental illness need the time and a place to have these curative successful experiences before they can move ahead in their lives with confidence. Utilizing psychological jargon I would say, positive experiences strengthen ego and when that happens enough, the illness process becomes weaker and the person’s upward mobile vitality and quality of life increases in dimension.

The strength based approach to treatment has its’ origins in the writings of Aristotle although its more modern development begins in the 17th century with Moral Treatment, an approach supported by John Lock and other early Humanists. Humanism, with its emphasis on the worth and dignity of all people, the commonality of human experience, the rejection of inappropriate authority and an optimism about the capacity of people, can be seen, as the first context in which treatment was based on strength building. In the world of serious mental illness, the idea that increasing existing capacity, as differentiated from improving current weakness, is first attempted in the Moral Treatment movement. The work of William Battie, William Turke, Benjamin Rush and Philippe Pinel, represents this new model of healing. For example, in England; York Retreat, started by William Turke, created a family style ethos where patients followed a daily routine of work and leisure and did chores to give them a sense of contribution. In the United States, Benjamin Rush, in the late 18th century, developed humane approaches to treatment by requiring hospitals to hire intelligent and sensitive attendants to work closely with patients. Reading and talking to them and taking them for walks. The 1920s saw the development of the residential living and learning communities such as Father Flannigan’s boys Town in the in USA, Homer Lane in England and Aicorn in Austria. These programs for disadvantaged youth in England were called Q Camps which stood for Quest and Query and practiced “Planned Environmental Therapy” developed by Psychiatrist Marjorie Franklin. This therapy was based on identifying the healthy aspects of a person in an attempt at restructuring attitudes and functioning in a residential social and community environment. (Wills, W. D., The Hawkspur Experiment, London, George Allen & Urivin, 1941). In the 1920s, the development of settlement houses in the USA was another strength based movement. Like Fountain House, it related to the concrete needs of people in the local communities and emphasized helping people fulfill the American dream through self help, empowerment, family and community support, training, social service assistance and recreational activities. This movement, which was extensively taught in social work schools had a powerful effect on John Beard through his social work training.

In 1945, as result of the poor job done after World War 2 with the so-called shell-shocked soldiers, two hospitals were set up in England to help cope with the psychiatric casualties of the war – North-field Hospital in Birmingham and Mill Hill in London. Under the leadership of Dr. Main at North-field and Dr. Maxwell Jones at Mill Hill, the strength based ideas embodied in these hospital based therapeutic communities gained full expression. “When the leader interacts at the level of the group, his power can be magnified rather than dissipated. “It is not so much the occupation of the group but the participation in the group activity which is the curative factor”. “Responsibility sharing and mutual self-help lead to a decrease in passivity and dependence and to the abandonment of the sick role”. “Negative sanctions are less effective than positive reward in changing behavior.” (Whiteley, S. The Evolution of the Therapeutic Community, Psychiatric Quarterly, Vol. 75, No. 3, Fall, 2004) Unfortunately the ideas developed in the therapeutic community movement failed to gain full realization because of conflicts between proponents of a strength based treatment approach and the proponents of the psychotherapeutic treatment approach. Later an offshoot of the therapeutic community movement called milieu therapy, focused professionals on the virtues and healing benefits of therapeutic social environments in non hospital treatment facilities. The practices inherent in these environmental practices would have a powerful effect on Doctor Arthur Pierce, John Beard’s supervisor at Wayne County hospital in Eloise Michigan where in 1950 they practiced Activity Group Therapy the immediate forerunner of the Fountain House strength based treatment approach.

In addition to the settlement house movement and Milieu therapy, another possible influence on Beard in his development of the Fountain House treatment model were the humanist psychologists of the 1950s who were his contemporaries. Although in the ten years I worked closely with Beard I never heard him mention Maslow, Rogers, Fromm, Horney or Jung or that matter any ideas or theories he labeled as humanistic. It was never the less true that he believed that staff should be authentic and offer members, acceptance while trying to develop an influential relationship. Beliefs very consistent with Carl Rogers client centered therapy. Also John felt strongly that all people need a feeling of rootedness, the opportunity to be creative, a sense of identity and a place to report good and bad news, a list of human needs identified by the humanist psychologist Eric Fromm. In general, Humanism in the 20th century, was a reaction to the pessimism and lack of human choice imbedded in both psychoanalytic and behaviorist theory, which optimistically speaks to our inherent potential as human beings and dates back to Aristotle’s idea that the individual is constantly trying to realize positive values from a core of human nature that moves from simple to complex, that relationships should be concerned with sharing, giving and taking care of each other, and that people act from both self benefiting and other benefiting virtues. (Jorgensen, I. S., and Nafstad, E.H., Chapter 2 in Seligman, 2004, p. 22-25). Nevertheless, as Rogers explained, there are negative events which can thwart a person’s natural upward movement and create pathology. As a result, this deep yearning for positive fulfillment can become weak and difficult to hear but can be stimulated to an increasingly noisy level by a social environment that supports it and by focusing on peoples strengths. This idea of belonging to a social environment that supports self fulfillment is echoed by Maslow who believed that belonging is a prerequisite to the development of a persons self esteem and self actualization. In Karen Horney’s “Neurosis and Human Growth”, the client has a built-in propensity for self realization. These hopeful notions are consistent Carl Roger’s Organistic Valuing Process, (1959), Abraham Maslow’s Self Actualization (1968), Jung’s Concept of Individualization, as well as John Beard’s belief that people have a “need to be needed”. By creating a real need for member assistance in the Fountain House community the focus on a member’s strengths, instead of a focus on pathology becomes a pragmatic necessity. Whereas other strength based approaches utilize verbal analysis and social persuasion to build confidence, at Fountain House self efficacy and self esteem grows through successes in real and needed activity. As Bandura states talk alone cannot achieve the consistent changes in human behavior that builds self efficacy and esteem. Also this need for member participation in all of the activities of the Fountain House community destroys the traditional hierarchical relationship between staff and members and paves the way for significant, authentic and mutual relationships.

While observing the treatment of the physically disabled at the Rusk Institute in New York City, Beard became interested in the fact that “prosthetic devices” and “ramps” created a hopeful reality for the disabled. If a person has no legs and can’t walk, creating artificial legs will allow him to walk, and if a person in a wheel chair can’t enter a building because of the steps, create a ramp so that he can. Observations that led him to the idea that “invisible social ramps” are what’s needed to help the seriously mentally ill adults readjust to community living. And these invisible supports are built every program that make up the Fountain House treatment model. Although John Beard never formally identified himself as a humanist or wrote down his ideas, given his optimistic belief in human potential, the Importance of relationships, the need people have to belong to a supportive community, he might have been recognized as a leading humanistic practitioner. This is particularly true when you consider his original conceptualizations concerning people’s “need to be needed” and “invisible social ramps”, contributions which were ground breaking.

There are three strength based modern day theories that are consistent with the Fountain House Working Community practices. The first, in 1997 is Bandura’s concept of self efficacy which defines an individual’s belief in their ability to accomplish tasks. According to Bandura, the best way to improve self efficacy is through participation in real as opposed to simulated activities. It is through this participation that a person can experience success (mastery), observe others successfully participating in similar activities ( a vicarious experience) and be inspired by others in an influential relationship (verbal persuasion). The second in 1985 is Deci and Ryan’s Self Determination theory, in which intrinsic motivation, a prerequisite for self actualization requires a place, a social environment in which the nutrients for autonomy ( the exercise of control and choice) relatedness (relationships with people who care) and competence (increasing self efficacy) exists. The third relevant incarnation marks the advent of positive psychology in 2001 which brings together theories and research that focuses on what people need in order to live a “good life”. The good life according to Positive Psychology involves optimal functioning, subjective well being and a focus on human strengths capacities and resources rather than human pathology. As it relates to Positive Psychology and the need for supportive environments Seligman and Peterson wrote “Using your signature strengths is concordant with your intrinsic interests and values; hence in a supportive environmental context the clients strengths will become evident. This does not typically happen in a prescriptive way such as having the client complete a strengths inventory, but it occurs spontaneously in the relationship.”

The Fountain House intentionally created working community treatment approach pre dates these three modern theories, but it has in common with them all of the essential elements for human growth and development. Also they all agree that in order for people to grow, a relationship rich place needs to exist, a place that has values, that offers a sense of belonging, the opportunity to model others, offers activities that are real not simulated and where choice is respected. Fountain House is clearly such a place but in addition to offering adults with seriously mental illness a sense of belonging it goes a step further by creating a situation in which they are needed to participate in all of the necessary practices and activities of the community and in so doing the Fountain House treatment approach breaks new ground. When you relate to a person’s need to be needed, an idea in the helping professions still not yet a part of most program designs, you celebrate humanity, confer dignity and emphasize belonging. By creating a situation in which the clients participation and input is truly needed both supports and fosters their self respect and because of the choice offered and the mutual gratitude expressed, an equity in the professional relationship is created.

Summery

Aristotle’s “Ethics” which emphasized treatment based on inherent personal strengths influenced the Humanist philosophers, John Locke and others in the 17th century. This then is the basis for the movement to develop Moral Treatments for the hospitalized mentally ill in the 17th – 19th centuries and the special Residential Living Communities for orphan children that sprung up in the 1920’s. After WW2, as it relates to the mentally ill, these two movements led to the creation of Therapeutic Community’s as the predominant and influential in hospital treatment model (1945) The idea that the environment or the place in which treatment was administered could influence outcome led to Milieu Therapy which utilized some of the practices drawn from the therapeutic community experience. Finally the Settlement house crusade and the humanist psychologists of the 1950’s directly influenced Activity Group Therapy the program that John Beard administered at a state hospital lead to the establishment of the strength based treatment of the Fountain House intentionally created working community.