This Journal entry features my first complete paper on the Windhorse clinical approach, written in 1992. I had been asked by Richard Warner MD to contribute a chapter to his edited book on Alternatives to the Hospital for Acute Psychiatric Treatment (1995). This paper was also published in the Journal of Contemplative Psychotherapy (1994) with new material on meditation practice. This writing coincided with my family’s move from Halifax, Nova Scotia, Canada to Northampton, MA where a committed group of us had formed to establish a new Windhorse therapeutic community. This community is still thriving in Northampton, MA. This paper describes the first major evolution of the Windhorse approach in Halifax, from 1989 to 1992… The founding Windhorse community in Boulder, CO (1981-1987) developed the initial paradigm of a full Windhorse clinical team embedded in a staffed therapeutic householdSimultaneously in Boulder and Halifax, this paradigm evolved to providing treatment teams that were tailored to each client’s unique condition, home and family situation, and available financial resources. This remains the primary way that Windhorse care is provided to people in extreme states. This paper describes the pioneering work of the Windhorse Halifax group, grounded in clinical experience and guided by core principles. During the writing, I received invaluable editorial feedback from Harold Searles, MD who was Dr. Podvoll’s primary mentor. He always reminded me that staff and the clients were equally caring for and learning with each other
Thank you for your interest,
The Windhorse Project: Recovering From Psychosis At Home
Jeffrey M. Fortuna, MA 1994
THE PRINCIPLES OF THEORY AND METHOD
There are four essential principles:
- Psychosis is a major disruption in the balance of the body-mind-environment system that dislocates the person from the functional reference points of ordinary life. An effective treatment program must work with all of the imbalances in the biological, psychological, social, and spiritual dimensions of the whole person.
- Significant recovery is a real possibility for anyone suffering in psychosis. The person’s intrinsic intelligence continually interrupts any psychotic turbulence with momentary experiences of insight and freshness that bring the person into more direct contact with his or her body and surroundings. This experience is a coming to ones senses, as if awakening from a dream, Such fragile moments are “islands of clarity” that must be recognized and protected as the seeds of recovery.
- Recovery can occur naturally when catalyzed by authentic therapeutic friendships in a home-like setting. Grouping severely disturbed people together in one place of treatment may risk the health of both clients and staff. An ill person is likely to become healthier when in the company of other healthy people in a sane environment.
- A Windhorse treatment team attends to the recovery of the client, and is also committed to the well-being of each team member, the client’s family, and the entire therapeutic community. The traditional meaning of a healing community resides in this wide-ranging intention.
These principles, when contemplated and experienced in clinical practice, arouse the cheerfulness and resourcefulness required to attend properly to someone on the arduous journey of recovery. This attitude is an antidote to the potential exhaustion of one’s compassion and resources, and is embodied in the name “Windhorse” that we chose for our service and community:
Windhorse refers to a mythic horse, famous throughout central Asia, who rides in the sky and is the symbol of man’s energy and discipline to uplift himself. Windhorse is literally an energy in the body and mind, which can be aroused in the service of healing an illness or overcoming depression.” (Podvoll, 1990. p.24)
These principles translate into a comprehensive method of care that is simple and effective and has withstood the test of time.
The method of care used in the Windhorse program is home-based team treatment. The pattern and cost of clinical teams vary on a continuum of intensity, depending on what is needed and the available financial resources. Three primary components comprise an intensive team (a partial team is less elaborate): (a) therapeutic household, with live-in housemate(s), established as the locus of treatment for each client; (b) basic attendance, a specialized form of therapeutic relationship, is provided by a team leader and several team therapists; and (c) intensive psychotherapy provided by a principal therapist.
A pattern of meetings, facilitated by the team leader and principal therapist, integrates the team’s activities. These meetings include: the weekly team meeting of team members and client, which is of central importance; the household meeting in the home with client and roommate(s); the team leader’s meeting with the principal therapist; the supervision meeting with team therapists; and family meetings with client and family members. If several therapeutic homes are in operation, then additional meetings include: a community meeting of all therapists and clients; an all-staff meeting; and housemate meetings of past and present roommates. These larger meetings are often held in team members’ homes and provide opportunities to socialize together. This meeting pattern gives structural coherence to the treatment situation, and avoids the fragmentation in care and in personal relations often found in situations with multiple care providers. These meetings form a matrix of social containment, which is essential since there is no fixed facility to give boundary to the therapeutic environment.
The principal therapist and the team leader organize the household and the team. They assess the client’s needs, capacities, and available financial resources, in consultation with the client and family. An affordable treatment prescription is then tailored to the client’s situation, by combining more or less of the primary and adjunctive components and the types of meetings. Such a design is adaptive to the uniquely evolving situation of the client, and future adjustments are made in adjustment in collaboration with the client and family. Each team is intended as decremental in size and cost over time, although the client’s social involvement with the Windhorse therapeutic community is encouraged after formal treatment has ended. We openly acknowledge the possibility of significant recovery but do not predict the degree or direction the recovery may take. In practice, we commit ourselves to be in empathic contact with the client’s present condition and life situation. the client’s present condition and life situation.
The forms of a Windhorse team are as varied as the range of clients’ unique life-situations. Our experience has shown that the most stable recovery from psychotic imbalance occurs in the familiar surroundings of one’s home, attended by gentle companion
THE DISTINCTIVE FEATURES AND IMPLICATIONS
The Windhorse program for recovery is a viable alternative to contemporary care offered in long term inpatient and residential settings. Each treatment team provides compassionate in-home care for a person enduring psychosis or its after-effects, to facilitate his or her recovery of a dignified and meaningful life.
In practice, the Windhorse program works with the imbalances in the biological, psychological, social, and spiritual dimensions of the whole person, as illustrated in the three clinical vignettes.
- Biological Dimension: The team utilizes a range of physical treatments in addition to psychiatric medications. Medicines are used sparingly, intermittently, and for as long as is necessary without committing to long-term maintenance regimes. Care is taken not to cloud the client’s awareness or to excessively blunt the level of arousal in order to maintain an optimal learning ability. This orientation is a source of dialogue with each team’s attending psychiatrist. Proper diet and behavior are emphasized, and appropriate physical therapies are considered, such as acupuncture, massage, or movement therapy. A schedule patterns healthy rhythms of daily living. Maintaining a clean and uplifted household is essential. Care of the body and the environment that promotes wellness is the ground of recovery and the context for the proper use of medication.
- Psychological Dimension: Basic attendance fosters the synchronization of the client’s body, mind, and environment. The forms of basic attendance are individual psychotherapy, practical or ordinary therapy, specialized group meetings, and family work, which are all integrated into a single team for each client. Gentle and disciplined friendships between staff and client gradually develop, which bridge the alienation that is usually the result of the psychotic disturbance, of cultural stigma, and of rigid professional distance. The client is able to recover hidden psychological resources of intelligence and courage within him or herself that are essential in overcoming the fears and self-aggression that shadow any psychotic episode.
- Social Dimension: Treatment and recovery are carried out under ordinary life conditions in individual households in the community. Grouping disturbed persons together in one place may risk everyone’s health, and reinforce stigma. The team attends to the boundary between the client and the practical tasks of living and working in the larger social world. The client is accompanied by the same therapists through all stages of recovery, eliminating the stressful transitions that clients experience when they are abruptly admitted to and discharged from discrete programs in sequential levels of care. The “revolving door” problem, such as going in and out of the hospital, is lessened, since the intensity and cost of the team adapt to the client’s changing condition. Client and family become active collaborators in the team as a micro-healing community, and the benefits of involvement are shared among everyone. This intimacy of mutual caring fosters bonds of human kinship similar to an extended family or clan.
- Spiritual Dimension: The Windhorse community does not promote any particular religious doctrine. It does cultivate a field of dialogue in which the broad range of staff and client experiences can be safely expressed and responded to. Clients repeatedly ask their care givers to listen, without judgement or denigration, to their cherished spiritual concerns, such as their relationship to good and evil or to the “divine.” Compelling glimpses of ultimate meaning always occur in some stage of psychotic disturbance. Similarly, staff may ask to explore the meaning of true compassion or the relationship between their personal spiritual practice to clinical work. Many Windhorse staff and clients have found contemplative disciplines to enhance self-knowing and to awareness beyond private concerns. Members of the Windhorse community are attempting to live productively and creatively together, enlivened by a spirit of learning. To engage in healing is traditionally a sacred art that attends simultaneously to the ill person and to other community members, and reharmonizes the community with the surrounding environment. This perspective joins social ecology and spirituality together in a time-honored way (Knudtson and Suzuki, 1992).
The future of mental health care is increasingly driven by the consumers/survivors of conventional treatments, which are influence by the medical model of psychosis as a brain disease best treated with brain medicine. Consumers insist on being offered humane, whole-person treatment alternatives. The medical model was once the promising alternative to outdated treatments, and it is reasonable to assume, since all models have historically proved to be provisional, that future paradigm shifts are inevitable. There are already signs of a transformation of Western medicine “from a narrow biomedical model to a biopsychosocial one” (Barasch, 1992, p. 36).
American mental health care is now in a crisis of rising costs, inaccessibility to shrinking community services, and increasing reliance on brief crisis hospitalizations and psychiatric medications (Dumont, 1992).
In addition, the political and economic alliances between the psychopharmaceutical industry and psychiatry are an increasing source of embarrassment to the profession, and the obvious conflicts of interest left unresolved will intensify the crisis. One can certainly rely on the occurrence of alternatives to any established system in a crisis of transition. However, as with psychosis, whether such outcomes are healing or destructive depends significantly on our actions now.
Note: this paper was first published in Richard Warner, MD’s book, Alternatives to the Hospital for Acute Psychiatric Treatment, 1995. It was also published in the Journal of Contemplative Psychotherapy, 1994, with new material added. The paper is archived on the Windhorse Guild website:
and is published on the WCS website:
Jeff received his MA in Contemplative Psychotherapy at Naropa University in 1980, and served on the Naropa faculty until 1989. In 1981, he co-founded the first Windhorse center, Maitri Psychological Services in Boulder, CO. From 1989 to 1992, Mr. Fortuna founded and directed a Windhorse group in Halifax, Nova Scotia. In 1992, he co-founded Windhorse Associates, Inc., and served as Executive/Clinical Director. In 2002, Jeff returned to Boulder as a co-director of Windhorse Community Services,Inc. He retired from his co-director role in 2013, yet continues to serve as a senior clinician and educator. He has taught widely, and written a book chapter and journal papers in the area of Windhorse treatment.