When Patients Run the Show: The Sderot Psychiatric Center's Puppet Theater/Commentary

Article excerpt

Adriana Katz, MD,1 Ruth Hadas, RN, BA,1 Tamar Beck, MA,1 Jonathan Benjamin, MD,1,2 and Shimon Scharf, MD, MPH1,2

1 Barzilai Medical Center, Ministry of Health, Ashkelon, Israel

2 Faculty of Health Sciences, Ben-Gurion University of the Negev, Beersheba, Israel

Abstract: Psychiatric rehabilitation combats the damaging effects of mental illness on living, occupational and social skills, and strives to help patients lead creative and fulfilling lives. Medical and social changes, as well as financial pressure, have all increased the need for community rather than institutional rehabilitation. New philosophical emphases highlight patient self-actualization and empowerment. This paper describes the development of a puppet theater, whose members and artistic director are almost all chronic psychiatric patients; the project has achieved steady sheltered employment status and been awarded the first Zussman-JDC prize by the president of Israel. Interviews with patients elicited major differences between patient perceptions of traditional rehabilitation frameworks and the theater. Theater is more creative than typical sheltered employment opportunities for mental patients, and puppet theater has unique aspects that may be especially suited to their needs. Patients found participation an empowering experience.


The overriding goal of psychiatric rehabilitation is the amelioration of the effects of psychiatric disease on patients' abilities to live independent lives, and on their social and occupational skills. This emphasis differs from that of treatment, which combats the disease itself. Psychiatric rehabilitation thus targets social, occupational and leisure skills, and emphasizes the re-integration of the patient into the community. The successfully rehabilitated patient can live an optimally independent and meaningful life (1). Schizophrenic patients are among the most severely affected groups of psychiatric patients (2) and their rehabilitation is one of the greatest challenges facing those responsible for chronic care, including patients themselves and their families.

In recent decades psychiatric treatment has changed, with the introduction of neuroleptic and other drugs, which greatly reduced certain symptoms, and enabled patients to live in the community. This was paralleled by the movement to "deinstitutionalization" (3), which promoted brief hospital admissions, and discharge of as many inpatients as possible. These developments created a need for preventive, supportive and rehabilitative services outside hospitals (4). This process has been accelerated recently by economic policymakers, who, rightly or wrongly, perceive community treatment as less expensive.

Simultaneously, changes in the approach to the quality of psychiatric rehabilitation have included a movement from paternalism toward autonomy, and a patient-oriented rather than an institution-oriented service; great stress is placed on increasing the individual's freedom of choice and his or her potential creativity (5). Some rehabilitation services seek to "empower" patients, in order to make them active partners in the planning, delivery and evaluation of the services. The central idea of empowerment is that people need to do things for themselves and for society in order to fulfill themselves as human beings (6), and that this is an existential need no less than it is a wise social policy (7).

Occupational counseling, training and placement are central aspects of rehabilitation. Unfortunately, work options for mental patients often involve routine, repetitive tasks, with little room for creativity or emotional expression. These kinds of work may lead to further stigmatization of patients, and foster "disempowerment." Here we describe the evolution of a unique occupational framework, namely a theatrical puppet group that had profound effects on the professional and private lives of mental patients in our community. …