Issue 11: May 2015

EDITORIAL
Schizophrenia, the most mysterious amongst all the mental disorders, often has a profound effect on the lives of the people
suffering from it. Persistent research and service endeavors focus on decoding the enigmatic nature of the disorder in order to
lessen its devastating impact on life and to aid individuals function effectively in their roles of choice.
Although the efforts of discovering advanced pharmacological solutions to treat the disorder are ongoing; current trends also
center on innovative approaches to improve the functionality of individuals with schizophrenia. Such initiatives range from
cognitive remediation programs to facilitating assisted and / independent living. Thus, the contemporary practice pivots on the
concept of 'reintegration', which aims at enabling individuals to function optimally despite the limitations caused by the disorder.
On these lines, then, it is vital to strike creative balance of optimism and realism while designing care pathways for reintegrating
individuals with schizophrenia back in the society. In this month's edition, we are glad to present two such programs that
eradicate the notion of equating schizophrenia with mindlessness and a downward course. One is a detailed account of the
concept of supported employment program for people with schizophrenia successfully tested by Dr. Kim Mueser and his team at
the Centre for Psychiatric Rehabilitation, Boston University. The second is an enriching narrative of an art based therapy
practitioner, on how his sessions with people with schizophrenia facilitate present moment awareness in them, helping them
reconnect with the reality and with their self. As we embark to open new routes of working with people with schizophrenia; these
two models provide the ethos needed in this journey!

INFO DESK
Tribute to Prof. John Nash
Nobel laureate American mathematician Prof. John Nash was known to the mental health field for
his struggle with schizophrenia. He died in a car accident on 23rd May 2015. TRIMITI pays tribute to
Prof. Nash and shares a link with its readers of an article about his life story written by Sylvia Nasar.

http://www.u.arizona.edu/~mwalker/NashStory.htm

Basic Training in EMDR

EMDR Association organizes training in EMDR (Eye Movement Desensitization and Reprocessing) Psychotherapy,
recommended by W.H.O. for children and adults. Dates: Mumbai 5th to 8th June 2015 / Bengaluru 18th to 21st June 2015.
Fees: Rs.12, 000/-. For more details, visit www.emdrindia.org

Issue 11 : May 2015

Supported Employment for Schizophrenia

Schizophrenia has a pervasive effect on individuals' daily
functioning, including work, with employment rates typically in the range
of 10-20%. Despite the high unemployment, most individuals with
schizophrenia want to work. Fortunately, there is now realistic hope for
the ability of people with schizophrenia to achieve their work goals,
through a program called supported employment.
Dr. Kim Mueser is a Clinical Psychologist and

What is Supported Employment?

Executive Director of Center for Psychiatric

Rehabilitation at Boston University, USA. He
has been involved into schizophrenia
research for more than 25 years now. Dr.
Mueser writes about core ingredients of

Supported employment differs from other vocational rehabilitation

approaches. Traditional vocational programs are based on a train-place
approach, in which prevocational skills training, or sheltered or
transitional work experiences, are required before an individual moves

'supported employment' which is an

onto competitive work. Instead, supported employment takes a place-

evidence based approach of helping people

train approach, which emphasizes first helping people find a competitive

with Schizophrenia obtain work.

job, and then providing the training and support necessary to succeed at
that job.

Supported employment services are provided by a team of employment specialists, with one specialist working with each person
to achieve their work goals. Supported employment is based on the following principles:

Desire for work is only

criterion to participate
Anyone who wants to work is
eligible for supported
employment. This means that
people with symptoms, cognitive
impairment, or problems related
to substance use can still
participate in supported
employment, and get and keep
jobs, as long as they want to work.

Rapid job search

The process of looking for a job
begins usually within one month of
the person joining the program,. A
vocational assessment informs the
job search, with the employment
specialist helping the person
identify and apply for jobs, and get
one. Prevocational skills training is
not provided before the job search.

Focus on competitive work

Supported employment helps people
find competitive jobs in integrated
community settings, and paying
minimum wages. These are the types of
jobs that most people with
schizophrenia want and can get.
Competitive work is valued more than
jobs that are set aside for people with a
psychiatric disability, such as sheltered
workshops.

Individual preferences
The personal preferences of the
individual with schizophrenia are
respected by the employment specialist.
This includes the type of job desired,
location, work hours, etc., and whether
the person wants to disclose his or her
psychiatric disorder to a prospective
employer. People who get work in their
areas of interest are more likely to keep
their jobs than those who do not.

Community-based services
Most employment services are provided in
the community, and not at mental health or
vocational rehabilitation centers.

Job Development
The employment specialist is actively
involved in the process of developing jobs
in the community, based on different
interests and skills that individuals may
have. This means being a member of the
community in which job searches take
place, cultivating relationships with
prospective employers and businesses, and
exercising creativity in spotting untapped
potential opportunities that can be turned
into paying jobs. As the employment
specialist stands behind and supports
people after they obtain jobs, strong
relationships with employers become a
major asset in developing new jobs.

Issue 11 : May 2015

Follow-along supports
After a job is obtained, the employment
specialist provides assistance to the client
to help them keep the job, such as learning
job duties, problem solving, giving
practical assistance (e.g., learning
transportation), liaising with the employer
(when person allows disclosure of
psychiatric disorder), collaborating with
family, and skills training to improve social
interactions.

Integration with clinical

services
Employment services are integrated with clinical treatment in order to
minimize the effects of symptoms and medication side effects on the person's
ability to work, and ensure support of the clinical team for the individual's work
goals.

Benefits Counseling
Individuals are informed about how obtaining work could influence any
benefits they receive related to their psychiatric disorder, and any incentive
programs that may help the person in pursing employment.

Functional Challenges in Job Placement and Retention

Helping people with schizophrenia find and keep
employment requires attention to their personal strengths
and weaknesses, and the functional challenges they
experience. Often employment is part-time, and may range

able to complete the job task, or a customer complaining about

something), and establishing and reviewing solutions to each
problem (such as contacting a supervisor), can resolve
problems that might otherwise get worse.

from as few as several hours per week to upwards of 10 or 20

hours per week. In general, symptoms do not pose a great
obstacle to the ability of people with schizophrenia to work,
with some exceptions. If the person has psychotic
symptoms, such as talking to voices or about delusional
topics, it is preferable that any work they do not be in a
public setting, where such behavior could be disruptive.
Such individuals can often work productively if they don't
have to interact with many people, and work can actually
decrease their psychotic symptoms. People with negative
symptoms may work more slowly than others, and therefore
work that needs to be done quickly or involves time pressure
may be less suitable for those individuals.
Cognitive difficulties can present a greater challenge to
successful job placement and retention. It is important to
try to match the individual's cognitive abilities with the job
responsibilities in order to avoid overwhelming the person.
People with cognitive challenges may require a longer time
to learn job tasks, and accounting for this in the days and
weeks after first getting a job is important. Tasks should be
broken down into simpler tasks or steps, with training
focusing on learning just a few steps at a time, lots of
practice, gradually increasing the number of steps, and
providing abundant reinforcement for effort and good
performance. People with cognitive difficulties may also
have more difficulty solving problems. Helping people
identify common problems in advance (such as not being

People with schizophrenia who have significant symptoms or

cognitive challenges often need the active help of the
employment specialist to successfully land a job, as well as to
keep it. With these individuals, part of the employment
specialist's role is to champion the person's ability to do the job
to the employer, and his or her enthusiasm for the job, often
before the employer has met the person. This prepares the
employer to be positively predisposed to the individual when
they meet, and aware that the person may not appear as
competent or motivated as they really are. This helps people
get their foot in the door of jobs they might not otherwise be
able to get, and their ability to learn and do the job helps them
keep it.
Not every job that a person gets in supported employment
works out, either because the person may have difficulty
performing it, or they may not like the work. These experiences
are normal, and provide opportunities to learn for both the
individual and employment specialist, so that the next job may
work out better. Once people get a job that seems to fit their
skills and interests, the amount of support needed to keep the
job gradually goes down, and often the number of hours they
work increases. Taken from this perspective, helping someone
get and keep work is an investment in the person's future,
which often pays off with the multiple benefits of work,
including pay, fulfilling a socially valued role, improved selfesteem, and greater community integration.

Issue 11 : May 2015

Research on Supported Employment

More than 20 controlled studies conducted throughout

Recent research has focused on ways of making supported

the world have shown that supported employment is

employment even more effective. Impaired cognitive

more effective at improving competitive work over two

functioning is an important predictor of work, including in

or more years compared to other vocational

people with schizophrenia receiving supported employment.

rehabilitation programs. Improved work outcomes

Cognitive remediation (or enhancement) is aimed at helping

include getting jobs, the number of hours and weeks

people improve cognitive functioning in areas such as attention,

worked, and the wages earned.

In addition to

memory, and problem solving, and involves a combination

improving the financial standing of people with

cognitive practice exercises and teaching skills for coping with

schizophrenia, work gives them something meaningful to

cognitive challenges. Controlled studies show that adding

do, facilitates community integration, improves self-

cognitive remediation to supported employment can improve

esteem, and leads to modest reductions in symptoms.

work outcomes even more, including in people who have not

Regular work may also help reduce relapses and

previously benefited from supported employment.

rehospitalizations.

How Families can Help

Family members can support a loved one with schizophrenia by understanding the benefits of employment, and exploring with
their relative whether he or she would be interested in work. People with schizophrenia are capable of working real jobs in the
community, and do not need to be steered into sheltered workshops designed for people with a disability. The key to successful
employment is helping people find jobs that match their interests and skills, in settings in which their psychiatric challenges pose a
minimum of interference.
Supported employment programs are becoming more available every day. However, not everyone can find a program near to
them. This is no reason for family members to give up hope for their relative experiencing the benefits of employment. Families
are in the ideal position to help their relative become a worker.

Family members can help by using the following tips:

Trust in the fact that your relative is capable of working a real job, despite symptoms or other challenges.
Talk about work with your relative, and explore if he or she is interested, and what types of work are most appealing.

Activate your social network (family, friends) to identify possible jobs that your relative could dodon't be afraid to sell

your relative's strengths!

Explore other possible job opportunities with your relative, keeping in mind his or her strengths, skills, and limitations.
Help your relative get a job by providing assistance as needed; this may involve you working out the details of job with the

employer.
Provide practical supports to help your relative get ready for the job and learn it, keeping in close touch with the employer

as needed.
Rest assured that the need for these follow-along supports is usually greatest right after the person gets the job, and

then goes down dramatically after that.

If the first job doesn't work out, don't give up, consider it a learning experience with your relative and try again.

Issue 11 : May 2015

Travel in rhyme every time

Mr. Aanand Chabukswar, is an Arts

A group of 12 people sits in a circle, absorbed in piecing together a popular Marathi

Based Therapy (ABT) Practitioner

folktale. 'Chal re bhoplya tunuk tunuk' is about a wizened old woman who

who works with World Centre for

encounters hungry predators (lion, tiger, wolf) while crossing a jungle en route to

Creative Learning Foundation

her daughter's house. The wise woman concocts excuses, promising the animals

(WCCLF), an NGO dedicated to action

that she would be in better health (chubbier) on her way back. This story, passed

research and training in ABT since

down through generations in varied languages across India, is embedded in our

2001. He has worked as a teacher and

memory. With a bit of prodding, each participant in the group recalls different

theatre facilitator for past 15 years in

versions and details. They have questions too: How did the woman recover from her

India and abroad. Here he shares an

illness? Whose idea was it to travel in a pumpkin, the mother or the daughter? Did

experience of his session dedicated to

she carry chili powder to blind the animals with? They also chant the rhyming verse

Present Moment Awareness with

and key dialogue, which is the title of the story. The participants are intrigued and

individuals having schizophrenia.

voice their thoughts earnestly.

This could be a scene from just about any classroom, but it happens to be an engaging Arts-Based Therapy (ABT) session at the
SAA's (Schizophrenia Awareness Association) Swanand Punarvasan Kendra day care centre in Pune.
The ABT sessions, conducted by the World Centre for Creative Learning Foundation (WCCLF), are aimed at building the attention
span of the shubharthis and encouraging them to interact with each other, thus reducing their sense of isolation and suffering.

Together we can
The WCCLF, an NGO, is committed to utilizing the arts for healing at the community, institutional and clinical levels. Since 2001, it
has been involved in research, development and training to create 'India-specific' ABT models. The ABT practitioners, who have
trained at WCCLF, reach out to more than 4,000 clients in 80 institutions across the country.
The WCCLF is currently working in tandem with Swanand. The above session included shubharthis in the age group of 23 to 60
years. They all have severe to medium intensity of symptoms. The shubharthis face several difficulties -- psychosomatic, social,
physical and intellectual. The ABT sessions weave-in a range of mindful and meaningful creative-artistic experiences that help
alleviate or bypass these problems.
The WCCLF's project also involves tracking responses through PANSS (Positive and Negative Syndrome Scale), a checklist and
qualitative data inputs by session observers.
The level of participation and response of every shubharthi is different. However, most demonstrate a certain staying capacity -an engagement with what is actually going on in the moment.

Art heals
ABT beautifully complements the SAA's goal of recovery and rehabilitation. The sessions begin with artistic rituals, which are
known elements for the shubharthis. With practice, they help in connecting awareness and activity. We say our prayers and focus
our attention on the sound of the Tibetan singing bowl. We greet each one individually, saying their names acknowledging
ourselves and responding to the group. Naming and identifying people as well as things is a simple but powerful anchor.
We engage the senses: one shubharthi talks about the 'red burning tip and grey ash and smoke' of the
incense stick. Another describes its scent as that of sandalwood, adding that she likes it. Simple vocal
exercises with singing, shouting, dramatizing and laughing encourage verbal expression and listening.
Props are used to communicate, create worlds, stories and metaphors. For instance, when we pass a ball
around, the process of calling out the name, throwing and catching becomes an exercise in concentration

and connection.

Issue 11 : May 2015

We move to music in regular patterns, after which new sequences are introduced, thus urging the shubharthis to use their limbs
for graceful, dance-like movements. These changes in the artistic elements draw their attention. They also challenge and delight
the participants.

Time to share
Circle-time is utilized to construct dialogues on various themes. So, say, we discuss recess time playing in school, appreciate the
colours and clothes that people are wearing or talk about the goals and activity plans for the coming months, and so on. These
conversations are varied, exciting and rich in flavour. In some instances, the shubharthis have come out of their shell, recalling
moments of their life, sharing memories or even just expressing their interest in what is happening around them.
Each one gets his/her space to share and listen. These dialogues often take place with images, before or after drawing sessions,
sometimes with drama improvisations or shared stories as well. The experience opens up their world and they start appreciating
the community they are in.
In one session, we dramatised scenes from 'Chal re bhoplya tunuk tunuk'. A young shubharthi volunteered to play each of the
animals and helped others to mark the places where the scenes would be enacted.
Another shubharthi, who is always inaudible and lost in hallucinations, played the old woman. She interacted with the 'animals'
without any prodding, and in fact, coordinated with a fellow shubharthi who played the pumpkin!

Thoughts abound
The shubharthis also questioned many aspects of the story in a different session. One of them asked how fair it was for the old
woman to make a false promise and deceive the lion, tiger and the wolf. Another remarked that it was just a children's tale, so did
it really have any worth? A third mused aloud that the story was about the power of wanting to and then getting well!

Their interest and engagement find a focus in such moments. One of the shubharthis chipped in saying, we are all
surrounded by the jungle. We are constantly being asked, 'khau ka tula? (shall I eat you?)' the predators' words.
Going further, he added that the woman was not using deception, but was only buying time because she was cornered and weak.
We all try that, he explained.
There was some silence following this assertion, after which another shubharthi said the story is about protection and having to
shield oneself in danger, like when we have delusions.
The one who had earlier spoken about it being a children's tale chimed in, I think there is no pumpkin. When she recovers from
her illness, she is a changed person. She is well-fed and her health is restored (dhasht-pusht) so she has become fat, like a
pumpkin. Much laughter ensued, but the myriad meanings of the words were not lost. One of the shubharthis simply said he was
listening, and had nothing to add to the discussion.

Here and Now

Each ABT session is brought to a closure with known parts and patterns -- de-roling exercises, songs and music suggestions by
shubharthis, some silence, meditation, prayer and closing rituals.
During every session, we confront questions, reflect on them together and put into practice the tools of the arts. In the process,
there is an improvement in their attention span and interaction. There are no labels of diagnosis and IQ levels here. Whatever
their state of mind with or without obsessions, hallucinations, thoughts or fears, there is a definite 'here and now' that they
experience. A possibility of beingof health.
It's not that there are no usual or unusual challenges, silences, non-participation, rigidity or recurring difficulties. We do face
them, but the sessions strive to make all these also part of the artistic and playful engagement. Difficulties enrich the artistic
tapestry of these sessions, while also bringing joy to the shubharthis.
Every ABT session at SAA has an itinerary of forming its own rhyme, just like in the story of the old woman. Despite the challenges,
there is a way to health and safety through the means of creative-artistic transformations.

Issue 11 : May 2015

EVENT
WO R L D S C H I ZO P H R E N I A AWA R E N ES S DAY C E L E B R AT I O N
On 24th May 2015, a Pune based NGO, Schizophrenia Awareness
Association (SAA) -organized a program on the occasion of World

The importance of the day:

Schizophrenia Awareness Day. The fourth of its kind. This year- the

Dr. Philippe Pinel, chief physician of

theme of the program was Human Rights of Persons with mental illness.

Bicetre Hospital in Paris freed individuals

While elaborating the theme further, Mr. Bakhshy, SAA's President

with mental illness who were chained to

stated that they thought of broadening it to other disabilities as well and

the walls of the hospital, in the late 18th

thus had invited Mrs. Meera Badve, Founder President of Nivant Andh
Mukt Vikasalay, an organization working for individuals with visual
impairment. The program began with musical and dance performances

century. To honor his humane and path

breaking work, 24th May is celebrated as
World Schizophrenia Awareness Day
across the globe.

by SAA's shubharthis and followed by the members of Nivant. SAA's

shubharthis also presented some yoga demonstrations.
Dr. Soumitra Pathare, a pune based psychiatrist, was the chief orator of the program. He shared the details of his ongoing project
with the Health and Family Welfare Department of Government of Gujarat, which aims at improving the quality rights of public
mental health system. The three years project which started in 2014 has three purposes: quality improvement through service
development, respect for rights of persons with mental illness and helping the public mental health systems move from medical
model to recovery model. The four government mental hospitals, three district hospitals and two medical colleges in Gujarat are
the nine sites of this project.

Dr. Pathare illustrated that the core idea is not to create new resources to improve service
delivery but to use available resources for the improvement. This will be achieved by training
the health workers, the hospital staff, forming family support groups etc. The intervention
package is based on WHO's Quality Rights' Toolkit.

The program's focus is re-orientation to recovery based model which emphasizes holistic, comprehensive and participatory
approach. The goal is to inculcate the key components of recovery like Hope, bring meaning and purpose in the life again and
control and choice, in the work of the public mental health service.
Mrs. Meera Badve and her team pointed out that society's sympathetic attitude towards people with disabilities is unnecessary
and emphasized that treating them with dignity and equality would aid in respecting their human rights.

TRIMITI Contact:
Ms. Chitra Khare: (+91) 98 90 72 11 76
Ms.Anushri Thakar (+91) 98 81 67 97 02
Write to us at: trimitifoundation@gmail.com

Designed and developed by Ms. Supriya Ghodake : (+91) 89 83 32 96 38

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