Strength-based approach in dealing with severe mental illness
Febna Moorkath1, G Ragesh2, Ameer Hamza3
1Department of Psychiatric Social Work, National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, Karnataka, India, 2Department of Psychiatric Social Work, Institute of Mental Health and Neuro Sciences (IMHANS), Calicut, Kerala, India, 3Department of Psychiatric Social Work, National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, Karnataka, India
Strength-based approach in dealing with persons with psychiatric illness gained more attention in the clinical setting mainly due to its unique way of addressing clients and their issues. It is a way of conceptualising and understanding people and their circumstances from the strength point of view and clinicians try to build-up from the core strengths, towards achieving client’s goals. The current article focuses on the utility of strength-based approach in a case with paranoid schizophrenia and tries to bring evidence-based case discussion in this regard.
Keywords: Psychiatric Illness. Paranoid Schizophrenia. Evidence-Based.
Correspondence: Ms. Febna Moorkath, PhD Scholar, Department of Psychiatric Social Work, National Institute of Mental Health and Neurosciences (NIMHANS), Hosur Road, Bangalore-560029, Karnataka, India. firstname.lastname@example.org
Received: 10 November 2018
Revised: 27 March 2019
Accepted: 15 May 2019
Epub: 30 May 2019
In the current social scenario, mental health problems and effective management are subjects for discussion and gaining attention compared to the earlier ages. For the past three decades, mental health professionals increasingly adopted core aspects of strength-based approach in care delivery. Viewing from a recovery paradigm, strength-based approach focuses on the inherent capacities of a person which can be converted towards empowerment. It avoids stigmatised and labelled language, and therapist adopts a way of communication which instills hope and enhancement of the strengths. In simple terms, it represents approaches that promote resilience as opposed to dealing with the deficits. It is solely based on growth, change, and collaborative relationship, and it shows promise in improving wellbeing and quality of life of persons with mental illness. This paper highlights a case description, mainly to focus on how mental health professionals can make constructive changes in the clients’ life by giving a platform to work with their strengths. Consent was obtained from the client for publishing the case and confidentiality was ensured.
STRENGTH-BASED APPROACH: NEW SIGHT AND NEW VISION
Strength approach tries to understand clients from their unique strengths and their innate capacity to move towards empowerment. This involves systematically evaluating survival skills, abilities, knowledge, resources, and desires that can be used in some way to help meet client goals. It highlights the fact that human beings have the innate capacity for growth and change. A review conducted to understand the effectiveness of this specific approach shows that strength-focused approach is associated with reduction in duration of stay in mental health setting, satisfaction with the care delivery, improvement in the attitude associated with recovery, improving educational and employment-related outcomes, and increased utilisation of services. Another study, aimed to gain insight about the use of personal strength in relation to recovery in adults with mental health issues, highlighted the importance of focus to the strengths for facilitation of self-efficacy and resourcefulness. This approach believes that people who are facing adversity and crisis become resilient and resourceful. They learn new strategies to overcome it and view adversities as the opportunity to exercise their resources and respond in culturally meaningful ways. It assumes that every individual and living environment has its own strengths.
The client is a 32 years old, unmarried, lady from middle socioeconomic status, urban background, educated up to post-graduation, and worked as a lecturer. There is family history of paranoid schizophrenia in father with no contributory personal and past history. The onset of psychiatric issues seems to be insidious and continuous course with the duration of 17 years. The clinical presentation of the client’s complaints predominantly reported to be marked suspiciousness, delusion of persecution, difficulty in reading and concentrating, and repeated recollection of painful and traumatic events along with significant socio-occupational dysfunction. The client has been diagnosed with paranoid schizophrenia. The early onset of psychiatric illness markedly affected the productivity of the client in education. The client discontinued engineering course due to multiple issues encountered due to psychiatric illness and joined other course once the involvement of the psychiatric symptoms reduced in its intensity. The maintenance antipsychotic medication helped the client to control her major symptoms but the associated psycho-social issues persisted, and it started to have major impact on the socio-occupational functioning of the client.
The assessment revealed childhood neglect in the form of discrimination in the extended family in terms of skin colour of the client, issues related to self-esteem, predominant self-stigma, and the client also expressed presence of stigma-related issues. The client had a significant issue associated with not getting married; it affected her occupational functioning where colleagues started asking about her marriage which ended up on the verge of resigning her job as a lecturer. The family environment has always been disturbed due to the constant verbal allegations between the client and family members. Even though parents were supportive, significant amount of caregiver burden in mother was observed wherein she has to take care of both the client and the husband. Mother’s constant effort to help the client was observed to be one of the strong family strength in this regard.
THE PROCESS: TOWARDS UNDERSTANDING - CAPACITY FOR GROWTH AND CHANGE - RESILIENCE
The strength-based approach clearly mentions that individuals have many capabilities, abilities, and strengths. Also, they have a range of experiences, characteristics, and roles, which contribute to who the person is and how he/she copes with the problem. In this scenario, the client deeply understood the fact that she was unable to cope up with the questions raised by the society but still able to work for years together. She was getting constant thought that she was mentally ill but she was able to complete post-graduation and get into a job. It rightly pointed out in the strength perspective research: “Clients manage to survive, sometimes against great challenges”. The client had the onset of psychiatric illness 17 years back when she was a first year engineering student and dropped her education. From that situation, she bounced back as a postgraduate with university top position. The strength perspective highlights the power of resilience in rebuilding the lives of people which help them to move with the hope. It highlights her ability to go on in spite of critical factors in her life. The therapists’ non-judgemental attitude and open mindedness are essential in working with the strengths of the clients.
ASSESSING THE STRENGTHS: IT IS THERE, IT ONLY NEEDS ATTENTION
Strength assessment asks the question, “What kind of life does the client want?” It concentrates on the client’s capabilities and aspirations in all areas of life’s functioning. The assessment revealed that when the client realised that financial independency can change the attitude of society, she started working towards her education and securing a job. The client was unable to see her strengths and attempts, she already made towards the betterment of her life due to the significant issues related to self-esteem (Figure 1).
INTERVENTION WITH THE CLIENT AND FAMILY
The client’s major concerns were to cope up with questions of colleagues about marriage and to provide guidance to achieve more academically. The therapist initiated active intervention by asking the client to list-out her strengths and the situations handled by the client which was later proved to be effective. Based upon this activity, mutual discussions were held regarding how to go about with her concerns. Involving the client’s family in the therapeutic process helped to gain more insights towards the client’s potentials and the strengths of the family as a whole. Working together with family members helped to identify the strengths and goals of the client. The therapeutic relationship with the client and family positively impacted on the outcome aspects.
From the therapist’s part, the major interventions were associated with strengthening the client’s belief system about her own capabilities and potentials, and conscious effort to focus only on the strength aspects and intentional avoidance of discussing on the deficit part. The sessions also focused on explaining the client the cognitive-behaviour connection and how it affects the action as a whole. The therapist actually prescribed positive self-talk and its connection with the strengths of the client.
EVALUATION AND OUTCOMES
The evaluation of the strength-based practice always lies in the client’s perspective in terms of whether goal attainment is continuously defined. The therapist along with the client prepared time table and syllabus-wise preparation strategies for appearing the University Grants Commission-National Eligibility Test (UGC-NET) and state teachers’ eligibility examination. With constant efforts, she was able to clear both the competitive examinations and currently working as a lecturer in a reputed college. This case illustration highlights the power of strength-based approach and the importance of the therapist’s role in focusing on the strengths of clients in rebuilding their lives.
In this case, viewing from a strength perspective, it demanded very frequent follow-up sessions and evaluations to keep up the motivation of the client. The therapist also observed that reassurance seeking was increased over a period of time. In view of lack of strong scientific research pertaining to the efficacy and procedure of strength-based approach, there exist practical difficulties.
- Tse S, Tsoi EW, Hamilton B, O’Hagan M, Shepherd G, Slade M, et al. Uses of strength-based interventions for people with serious mental illness: a critical review. Int J Soc Psychiatry. 2016;62:281-91.
- Pulla V. What are strengths based practice all about? In: Pulla V, Chenoweth L, Francis A, Bakaj S, editors. Papers in strengths based practice. New Delhi: Allied Publishers; 2012:1-18.
- Saleebey D. The strengths perspective in social work practice: extensions and cautions. Soc Work. 1996;41:296-305.
- Aarti R, Sekar K. Strengths perspective in mental health (evidence based case study) [Internet]. In: Strength Based Strategies - 2006 [cited 2018 Nov 10]. Available from: http://www.strengthbasedstrategies.com/PAPERS/16RanganFormatted.pdf
- Weick A, Rapp C, Sullivan WP, Kisthardt W. A strengths perspective for social work practice. Soc Work. 1989;34:350-4.
- Xie H, Yuan P, Cui SS, Yen MS. A study to examine the uses of personal strength in relation to mental health recovery in adults with serious mental illnesses: a research protocol. Health Psychol Res. 2015;3:2209.
- Early TJ, GlenMaye LF. Valuing families: social work practice with families from a strengths perspective. Soc Work. 2000;45:118-30.
- Rutter M. Resilience in the face of adversity. Protective factors and resistance to psychiatric disorder. Br J Psychiatry. 1985;147:598-611.
- Ronnau J, Poertner J. Identification and use of strengths: a family system approach. Children Today. 1993;22:20-3.
Moorkath F, Ragesh G, Hamza A. Strength-based approach in dealing with severe mental illness. Open J Psychiatry Allied Sci. 2019 May 30. [Epub ahead of print]
Source of support: Nil. Declaration of interest: None.
This work is licensed under a Creative Commons Attribution-ShareAlike 4.0 International License.