Thoughts From the Clinical Director: Soft Institutionalization

We all work in rehabilitation because we want to help other people, right? Giving more help is always good, right? Well, not always. I sometimes have talked about the difference between help and support. Where help is doing something for someone that they cannot do for themselves and support is creating an environment in which a person learns to help themselves – i.e. learn and grow. The challenge of rehabilitation is an act of continuous triage in which we are always adjusting our expectations of what clients can do for themselves, encouraging them to reach a little bit beyond their current ability and comfort zone. If we expect too little, they don’t grow. If we expect too much, they fail or lose hope and then we put in even more help which can maintain them in a state that requires a high level of input from staff, in other words: institutionalization.

Most of us at Buchanan understand that human beings deserve human rights and that people should be supported to live as independently as possible. But sometimes our desire to be kind by over-individualizing care or overly-lowering our expectations of what are clients can do for themselves leads to de-skilling and dependency. While most people have come to see that institutionalization is a harmful thing to the human spirit, we still inadvertently bring about dependency in our clients through a distorted form of kindness – this is what I call soft institutionalization. Growth and learning require a certain amount of destabilization and discomfort and mistake. If we try to shelter clients from destabilization, discomfort and mistake, then from our kindness we are creating soft institutionalization.

Soft institutionalization occurs as the result of a series of small things that prevent a person from taking on more responsibility. I sometimes think of this as the “negative Buchanan bubble.” This is where a client appears to be functioning well at Buchanan because of numerous small things that we do to shelter them from the reality of responsibilities that they will have in the community. This creates a kind of pseudo-independence. If we shelter clients from the consequences of their actions, we interfere with learning opportunities.

Some examples of soft institutionalization would include: providing transportation for clients instead of challenging them to take the bus, keeping them at Buchanan past the time that they are actively learning and growing, lowering our level of expectation to a person’s current level of functioning instead of always challenging them out of their comfort zone, and making exceptions to BRC/ADHB policies (what in the outside world is called reality) to promote patient comfort over adaptation. While it is true that reality in the community can be harsh, the goal of rehabilitation is to provide clients with the tools and skills to adapt as much as possible to that reality. The goal of rehabilitation is not to try to create an alternate reality that shelters clients from discomfort as that prevents learning opportunities. Everyone at BRC (staff and clients) should be on a journey of growth and learning – that is what working in rehabilitation is all about.

After my last “thoughts” column, Mars had written a nice response and she said that I could quote her statement, “good will always continue,” this was in regard to the question of when is enough, enough? The good that we do at Buchanan, in terms of compassion and inducing hope, does stay with people after they leave. I would add to this that growth will always continue. If we, as staff are continually growing, we teach by good example. If we have taught clients growth while they are at BRC, that growth will continue. If we have not modeled growth and taught growth, then we have not done any real rehabilitation work.

I know this concept of “soft institutionalization” is a difficult one and I do not feel I have totally explained myself on this topic. It is another “work in progress” in which I am still growing.

 

The Real Work

There is one thing in this world that you must never forget to do. If you forget everything else and not this, there’s nothing to worry about; but if you remember everything else and forget this, then you will have done nothing with your life.

It’s as if a king has sent you on a journey to do a task, and you perform a hundred other services, but not the one he sent you to do. So human beings come into this world to do particular work. That work is the purpose, and each is specific to the person.

You say, “But I spend my energies on lofty enterprises. I study jurisprudence and philosophy…and medicine and all the rest.” But consider why you do these things. They are branches of yourself…but remember the deep root of your being.

(Rumi)

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